GW1-2022-10787_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bill Kennedy 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name 7 ft. ft.
2834-A J60 ft. S rt.
cf'or+•x
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca wells OR LINER if tl a catile
FROM TO DIAMETER T<CKNESS MATERIAL
Kennedy Well Drilling II. I Vrt. 6.25
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
/9 Y a' FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: �'t/ ft. ft. is
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 bIATERrAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 f ft.
Non-Water Supply Well: - - - - -'
ft.
❑Monitoring ❑Recovery
Injection Well: (t.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa -F
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(color,hardness,seat ck• ..' fa'!k ite!)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
7 p F� 02
4.Date Well(s)Completed: TJ�Well ID#
ft. ft.
5a.Well Location: 90 nn ft. -R.
�ll��iCtF'JPi�� l��Bu��l tt. tt. era, :.t�U
Facility/Owner Name Facility ID#(if applicable)
'yl /f �� ft. ft.
/ ��i t'�✓I tGt C�i f`�(" ft. ft.
Physical Address,City,and Zip 1.REMARKS /
�akff
el
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N W � - 3
Sigua Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15-4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 9' S or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fdl out known well construction information and explain the nature of the
repair under#21 remarks 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 may also attach additional pages if necessary.
For multiple injection or non-watersupply wells ONLY wit r the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r 30� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'Janndd 2@1001 construction to the following:
10.Static water level below top of casing: 7r/ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter, 6.25 (in.) 24b.For Iniection Wells ONLY: In addition 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
12.Well construction method: 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) aL Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite "� well construction to the county health department of the county where
13b.Disinfection type: Amount: 1 �J>
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013