GW1-2022-01452_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy „t'� FROM14.W TER ZONES
'sue" FROM TO DESCRD.TION
Well Contractor Name
2834-A "' 1� �` 3SSf`' All,
9 © 15.OUTER CASING for mu ' wells OR LINER if a licable
NC Well Contractor Certification N®ber '" .C�'�C� FROM TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling ft- 6.25 in. sDR-21 PVC
Company Name 16.INNER CASINC OR TUBING eothermaI closed-loo
FROM TO DIAMETER THIC'IONFSS MATERIAL
2.Well Construction Permit#: �yo � R• h• 'a
List all applicable well permits(i.e.County,State,yariare;�njection,etc.) fl ft.
in.
3.Well Use(check well use): 17.SCREEN
Wat upply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
gncultural Pot_k.." TArYYI ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) LAesidential Water Supply(single) ft ft iry
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 20+ ft. Bentonite Hydrate ships in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Grotmdwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENTME-M D
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R,
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardy soil/rock a svc,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft q , L
it. a iL. .
4.Date Well(s)Completed: /01 -I/Well ID# ft. OZ ft. d
5a.Well Location: tt. fr. / d1clG
R-cam a � ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1nG ft ft.
Physical Address,City,and Zip 21.REMARKS
Ol County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one iat/long is sufficient)
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� Signature Certified Well Contracto Date
6.Is(are)the well(s): 21 ermanent or ❑Temporary 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.0100 Well Construction Standards and that a
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7.Is this a repair to an existing well: ❑Yes or 0 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the name 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
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
/ SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: �b (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water 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
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24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: A'4n!`�/ 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 276994636
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) o� Method of test: Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount: well construction to the county health department of the county where
Ln�
constructed. t
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Watei,Resources Revised August 2013
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