GW1-2022-10843_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Bill Kenned 14.WATER ZONES
y y FROM TO DESCRIPTION
Well Contractor Name kkgLft. �•1 R.
2834-A Vc�R.
NC Well Contractor Certification Number 15.OUTER CASING for mul US)OR LINER if a Iicable
FROM TO DIAMETER r THICKNESS MATERIAL
Kennedy Well Drilling R. I qA R. 6.25 In. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-100101)
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: �Lr'Cn R. ft. in.
List all applicable wvell permits(i.e.County,State, Variance,Injection,etc.)
ft. R. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Mum�ci aUPublic
❑Geothermal(Heating/Cooling Supply) e�K sidential Water Supply(single) ft. R. in.
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM To DESCRIPTION(color,hardness soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. R.
4.Date Well(s)Completed: o-Well ID# ft. R. 6
5a.Well Location: ft. ft.
Facilityi� Owner Name Facility ID#(if applicable) t L- -.,
300 "Q yCI nab c -Q Qar OCOcl^ ft. ft.
Physical Address,City,and Zip 19 /OtU 7 21.REMARKS
2922
A �C1_._ # 7 f5 ,�
( C`S1 ��SCD ,rra�a n fir,^ ,
County Parcel Identification No.(PIN) D% Q1 c3OG^
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/long is sufficient)
N W
Signature Certiticd Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing this form,/hereby certify,that the wells)was(were)constructed in accordance
with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9<0 copy of this record has been provided to the well owner.
Ifthis is a repair.Jill out known well construction information and explain the nature ofthe
repair under 421 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: 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 49 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2�@J100') construction to the following:
10.Static water level below top of casing: -7 0 (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:', In addition to sending the form to the address in
rota 24a above, also submit a copy off this fort within 30 days of completion of well
12.Well construction method: ry 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
13s.Yield(gpm) l 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: a. well construction to the county health department of the county where
constructed. I!
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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