GW1-2022-03069_Well Construction - GW1_20220307

1 :
WELL CONSTRICTION RECORD G
For Internal Use ONLY: 1
This form can be used for single or multiple wells k
1.Well Contractor Information: It
BI{{ Kennel 14.WATERZONES
Y 1 FROM TO DESCRIPTION
%Vc*ContractorName (L �O ft. I lax An
2834-A
NC Well Contactor Certification Number 15.OUTER CASING for mnitlerued wells OR LINER if a cable
FROM TO DiAMt' I..
M THICKNESS MATERIAL
Kennedy Well Dulling 0 FLA ft- 6.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING anal closed-loop)
FROM TO I DIAMETER I THIC1QgM I MATERIAL
2.Well Construction Perrmt#. 705 R. IL to
List all applicable we11 permitf C e_County,State,Variance.Injection,etc.) it.
3.Well Use(check well us* 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLO'rSM THICkNM MATERIAft
❑Agriculnttal ❑� MMu!unicipal/Pubfic In.❑Geothermal(l ieating/Cooling Supply) Hltesidentisl Water Supply(single) ft. in
❑Industrial/Commercial ❑Rescidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hr` on 0__ R. 20+ IL Bentonite Hydrate grips in place
Non-Water supply WeP_
❑Monitoring ❑Recovery
Injection Wen: R ft
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVE,L PACKiffavalicabled
❑Aqutifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI ACEMEAT METHOD
R. R.
❑Aquifer Test I ❑Stormwater Drainage tL
❑Expedm ace ental Technology ❑Subside Control
20.DRILLING LOG aificb eddttlonal sheets K neressa
❑Geothermal(Closed Imp) ❑TMccr FROM I TO DESCRIVIONcolorbrarde soiVrock typ4 Vidasizeem
❑Geothermat eatin CoD Return ❑Other(explain under#21 Remarks) 1) ft. fL
4.Date Well(s)Completed.al-17 Well ID#
5a.Well Location: iL fL
arwaCS �, fTGG[�lte�( tt, ft.
FactTrt`y//OtwnerName ` 1/ Facility ID#(ifapplicable) fL ft.
fL IL
Ph}sical Address,City,and Zip 21.REMARKS
County Pared identification No.(PIN)
5b.Latitude and Longitude in degrees/mhtotes/seconds or decimal degrees: 2L Certification:
(if weft field,one Iavbng is sufficient)
"- Sign fCertified Well Contiactoro Date
6.Is(are)the well(s): it7Yee=rminent or ❑Temporary gy signing this form,I hereby certify that the uell(s)nvs(irere)constructed in accordance
wsith 15A NCAC 02C.0100 or 15A NCAC OK_0200(fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 990 copy of this record has been provided,to the ndl owner.
if this is a repair fill out Ibrmrn trell construction information and explain the nature of the
repafrmrder#21 remarks section or on the hack 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 wens constructed. _ construction details. You may also attach additional pages if necessary.
For maniple miecrum or no*4svnT suppdy imils ONLPuith the same oanstruetian,you can_
submit one form. SUBMITTAL INSTUC IONS
9.Total well depth below land surface: !y7 (ft,) 24a.For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdi ferent(example-3Qa 200 and F@ 100) construction to the following:
10.Static water level below top of casing: (ft} Division of Water Resources,Information Processing Unit,
Ifwater ktid is above cash&use'+^ - ""� 1617 Matz Service Center,Raleigh,NC 27699-1617 "
11.Borehole diameter: 6.25 (in) 24b.For Iniection Wens ONLY:,In addition to sending the form to the address in
24a above,also submit a copy of this form within 30 days of completion of well
IL Well construction method:f olary construction to the following:
(Le.auW,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-16%
13a.Yield(am) a Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131 Disinfection type: granularhYPu�n� Amount: ��� well construction to the county health department of the county where
constructed
Forst G%V-1 North Carolina Department of Environment and Naluial Resources-Division of Water Resources Revised August 2013