GW1-2022-01734_Well Construction - GW1_20220207

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WELL CONSTRUCTION RECORD For interna►Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy Fn MATE TO RZONES DESCRIPTION
Well Contractor Name fL G ft ® { rr'
2834 A R ft.
NC Well Contractor Certification Number 15.OUTER CING Ifor nulMdwellO cable
DxE RINi
FROM R MATERIAL
Kennedy Well Drilling Q 1" 3& ft 16.25 in. I SDR-21 PVC
Company Name ^^nn 1D 91�f 16.INNER CASING OR TUBING eothermal dosed400
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2.Well Construction Permit#: I 'QQII 3 1 o FROM ft. R. DIAMETER in. THICIUHESS MATERLU
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List all applicable well permits(;.e.County,State,Variance,Injecdon,etc.) ft. R, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu/�nicipal/Public IL it In.
❑Geothermal(Heating/Cooling Supply) !?9.iticntial Water Supply(single) ft ft In
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft. 20+ (L Bentonite Hydrate chips in place
Non-Water Supply Well: M IL
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. IL�
❑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,soilfroek qpe,gr2in dze,ere
❑Geothermal(HeatinglCooling Return ❑Other(explain under#21 Remarks fL 'L l / 1
4.Date Well(s)Completed: -2`a1'. Well ID# It. M ft lOen
fL Oft.
5a.Well Location:
-Aare �,it� "�
0- iw.' !2' � oZ�ft.hehOG�
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Facility/Own"Name Facility ID#(if applicable)n I. <L
S/3.� Sa ti er Cf/v t1 2 7Physical Address,City,and hp
® 21.REMARKS
9aA01.4 _770y!7,3/g 3 FEB
0 7 2022
County Parcel identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:;
(ifwell field,one lat/long is sufficient) 22.Certification: t Fr t_
itCr°e i�Yo./Lri..�-vie`+•= 13�
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N W �� -11daa
Signature ertified Well Contracto Date
6.Is(are)the well(s): Oermanent or ' OTemporary By signing this form,I hereby term that the wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Egq-o copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and erplain the nature ofthe
repair under#2I 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
S.Number of wells constructed: l 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: fg-5- (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (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 Infection Wells ONLY: In addition to sending the form to the address in
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.sugar,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) 30 Method of test Air 24c.For Water Supply&Injection`Wells:
Also submit one copy of this farm within 30 days of completion of
granular hypodtoirite well construction to e county health department of the county where
136.Disinfection type: Amount �QdL th
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013