GW1-2022-01559_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: Nr-"
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Bill Kennedy cam ' f1� rl FR WATER ZONES
Y Y © •(,�• FROM TO DESCRIPTION
Well Contractor Name �1 a r �� f.•;='O1 ft. ft.
2834-A �t�c ^ `' ft. ft.
C,
15.OUTER CASING for mul' ells OR LINER it a licable
NC Well Contractor Certification Number
•:`,• FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling �: IL fL 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal close(Woo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit# D6e6��.7 oC� ff. ft. 10
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL fL to.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20+ fL Bentanite Hydrate ships in place
Non-Water Supply Well:
ft. fL
❑Monitoring ❑Recovery
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation FROM 19.SAND/GRAVEL PA TO CK rf a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardo soillrock a rain size,etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks D 2 O ft-
ft. t t
ft.
4.Date Well(s)Completed: Well ID#
ft. R.
5a..Well Location: ��, ft. ft.
?j c+,l f[VCE.-5 [.Lt1 ft. ft.
Facility/Owner Nam Facility ID#(if applicable)
fL ft.
/!r.jJilrl/lif �A' 5�.2 ft. ft.
5 Physical Addrr City,and Zip 21.REMARKS
I 773599`I�Y '
Q County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W /,)�J aaoo2
��� Signa ertified Contractor49- Date
6.Is(are)the well(s): [3'Permanent 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 121No copy ofthis record has been provided to the well 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 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: )�S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and-12@1001 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.*'
iameter:•6.25 (in.) 24b.For Iniection Wells ONLY: Indaddition 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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) y2 Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: ex,Granular Hypochlorite well construction to the county health department of the county where
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constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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