GW1-2022-10785_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells If
1.Well Contractor Information:
'14.,WATER ZONE&�.�'
Billy Kennedy FROM TO _ DESCRIPTION
Well Contractor Name so ft. ft.
2834-A 190 ft. )91
15.OUTER CASING for TLq:c wells)O%Wap�ticiille).
mAINC Well Contractor Certification Number mom I TO T I MATERIAL
Kennedy Well Drilling 0 R- I 3-q ft- 16.25 1n1 SDR-21 PVC
Company Name 16.INNER CASING ORT ING(geothermal closid,hiop)-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 9: l ft. ft. in.
List all applicable well permits(I.e.County,State,Variance,Injection,etc.) ft. ft. In.
3.Well Use(check well use): 17.,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.'
LIAgricultural [IMunicipal/Public . .
DGeothermal(Heating/Cooling Supply) PK-.'i'd.tial Water Supply(single) ft ft
to
DIndustrial/Cornmercial OResidential Water Supply(shared) 18.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 R. 20+ R- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
oMonitoring ORecovery
Injection Well: ft. ft.
E3Aquifcr Recharge OGroundwater Rernediation 19."SAND/GRAVEL PACK if applicable),
FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Storage and Recovery 08alinity Barrier ft. ft.
DAquifer Test 0 Stormwater Drainage ft. R.
oExperimental Technology El Subsidence Control 10.,DRELLING LOG(nitach additional sheets if necessary)
ElGeothermal(Closed Loop) 13Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grgin etc.)
0Gcothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 'L J ft. V
4.Date Well(s)Completed: [L-4-Z-5vell II)# ft' /_5 ft' &14A.&Le -
W5-ft. 051641,47C k-
5a.Well Location: ft. ft.
V!��4 1 1—
A (5e111;k1 ,P 0,1 ft. ft. U !t .
Facility/Owner Name Facility ID# if applicable) ft. ft. r 9 2927
6 Id f A_ ft. ft. J
Physical Address,City,and zi7 21.'REMARKS
00re, OQ020
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-.
(if well field,one lat/long is sufficient)
N W
Signattdof Certified Well ConttfA-r ba'te
6.Is(are)the well(s): Ofermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [:]Yes or 214o copy of this record has been provided to the will owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 36 —(ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 0-) 24b.For Iniection Wells ONLY: 11n addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 01 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: 100>' well construction to the county health department of the county where
constructed.
I .
Form GW-1 North Carolina Department of Environment and Natural Resources- esources Revised August 2013