GW1-2022-03133_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD For mtemal use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information
14.WATER ZONES i
Billy Kennedy FROM To DESCRIPTION
Well Contractor Name ft. ft.
- ----
2834-A rt. ft,
NC Well Contractor Certification Number 15.OUTER CASING for mufti-ca 'ells)OR LINER If a ticable
FROM TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling 0
rt. ft- 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotherma]closed-loop)
A �t FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable well permits(i.e.Counm,State,Variance.Injection,etc.) in
ft. ft.
3."'ell Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural CMunicipal/Public
ft. ft. In.
❑Geothermal(Heating/Cooling Supply) 2rkQidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experuneutal Technology OSubsideuce Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Jeotor,hardness soill o k h7e,xmin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) It. ft.
R. a ft. ti
4.Date Well(s)Completed:oZ. oZ9-Well ID# it. tt. 7
Sa.Well Location:
r ft. ft.
C7•/ �
Facility-'Owner Name ,Q Facility ID#(ifapplicable) MAR 0 ft. ft. 7 7,027
f
rbysual.Address,City,and Zip It.REMARKS
R n A j)eq 4 11H 2��(. 77 7 7 N tka "N PR I t
County Parcel Identification No.(PIN)
5b.Latitude and L igitude in degreeslmittutes(secotads or decimal degrees: 22.Certification:
(if well field.one IaUlong is sufficient)
N W
Signature o rtifi d Well Contraetor Date
6.Is(are)the well(s): 261.anent or ❑Temporary By signing this form,1 hereby certity;that the wellls)was(here)constructed in accordance
�7v� with 15A NCAC 01C.0100 a)- C' C•15.4 NCA 02 .0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or W0 copy of this record has been provided to the xell owner.
1J7his is a repair.fill out knourr well construction information and explain the nature of the
repair under t)21 remarks section or an the buck 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 ifnecessary.
For multiple injection or non-water supptr wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: l if:J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifati ferent(example-3(d100'and 2L100'))/{ construction to the following: i
10.Static water level below top of casing: T J (ft.) Division of Water.'Resources,Information Processing Unit,
t f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 21699-1611
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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
11.Well construction method rotary 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
13a.Yield m / Air 24c.For Water Supply&injection Wells:
(gp ) /t5 Method of test Also submit one copy of this form within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount: constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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