GW1-2022-10766_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 11&WATER LANES ID3CRIMON
Well Connsemr Name V V fL ast R. ^
2834-A fi0" ,i ft e"
NC Well Contractor Certification Number 15.OUTER CASING far mufficilled wells OR 2.INER K
FOM R TO DIAMETER THICISNL% MATERIAL.
Kennedy Well Drilling D R I 3,5r FL 16.25 SDR-21 I PVC
Cotsparey Name 16.INNER CASING Olt TUBING hermal closed-loop)
FROM TO DIAMFIF.R THICKNIc S MATERIAL
2.Well Construction Permit#: Ft. R ia-
List all applicable well ins mus(ve,County,State.Yoriance,Injection,etc.) h. ft.
ia.
3.WNI Use(check well use): 17.SCREEN
Wate pply Well: mom IN) DIAMCIRR SLOT SIZE TtI1Cgi6a MATERIAL
gnculmral ❑MunicipaVPublic R R is
DGeothermal(Heating/C in ing Supply) ❑Residential Water Supply(single) I ft' la
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
PROM TO MATERIAI. EMPLACEM[NTMLTROD&AMOUNT
oIrrigation 0 h• 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
R R
OMonitoring DRecovery
Injection Well: R R
DAquifer Recharge OCtroundweter Remediation 19.SAND/GRAVEL PACK e
DAquiftt Storage and Recovery DSalinity Barrier FROM TO MAlEi11A1, EMPWCEMENT METROD
R R.OAquiftt test OStormwater Drainage R tt
❑Experimental Technology DSubsideace Control
26.DRELLING LOG attach additional.heem R
OGeothernml(Closed loop) DTracer PROM To DT_RCm ON loan,bandues,mierarL iris,grain runs rue)
OGeothermal (Heating/Cooling Return) DOther implant under#21 Rentarks 0 R Rin.
Ae
4.Date Well lo�s)Completed: r—a-�a WeII ID# R �.
�O
5a.Well Location: ft. ft. -
i
R R
Fwl*/O er Name ®FacOiry lDp(if applicable) R R _
T66 W I'll 9 A. F J S 202"
Physical Ad S.city,and Zip 21.REMARKS
Abi 76y rys-odaff
County I Parcel rdcru fieatbn No.(PM)
5b.Latitude and Longitude in degrees/minutes(sexonds or decimal degrees: 22.Certification:
field,one latllong is sufficient) a
�� Signature, CMrfied Well Contractor Link,
6.Is(are)the weUhi): C <.e newt or OTemporary @y signing Uu form,!hoeby rertijy tkm Ue well(sJ ww(wraeJ cowtrvctad in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cowoucdon Standards and that a
7.Is this a repair to an existing well: DYes or C40 copy ofthu record has been Molded in dw well owner.
Ifthis is a repair,fill out Mown well coMruction information and explain the nature oftke
repair under 021 merselet section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: ' construction details. You Prey also attach additional pages if necessary.
For multiple injection or non-watersuppn,welts ONLY tons the suer consnvcnon,lnu can
submit oneforen. ) SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: / S (ft.) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells liri all depths ii(diferear lexample-3Q200'andr2@10/01 construction to the following:
10.Static water level below rap of acing: 0(...7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,we '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 On.) 24b.For Injection Weth ONLY: In additiaa to sending the form to the address in
rotary 24a above, also submit a copy of this form within 30 days of completion of well
IL Well construction method: construction to the following:
(m auger,notary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) s] Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: aaadar hypochDinte Amount' well consnuctioa to the county health department of the county where
constructed.
Form GW-1 North Carelira Department of Environment and Natural Resources-Division of Water Resources Revised August 2013