GW1-2022-03134_Well Construction - GW1_20220307

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
,,t 14.WATER ZONES
Billy Kennelly FROM TO DESCRIPTION
Well Contractor Name R. tL 3
2834-A 0 r Je.J.�.
NC Well Contractor Certification Number15.OUTER CASING for mul hied wells OR LINER f a lieeble
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 1- fL 6.25 in. I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
FROM TO DIAMETER TiUCKNFSS MATERIAL
2.Well Construction Permit#: eLO a �DO�n 7 o2S ft. fL
List all applicable well permits r e.County.State,Variance,Injection,
fL fL In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑Municipal/Public
fL
❑Geothermal(Heating/Cooling Supply) l�dential Water Supply(single) fLin
❑lndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO _ __MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri lion 0 fL 20+ R Bentonite Hydrate chips in place
Non-Water Supply Well:
tL R
❑Monitoring ❑Recovery
Injection Well: tL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liceble
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier IL fL
❑Aquifer Test ❑Stonnwater Drainage tL fL
❑Experimental Technology ❑Subsidence Control
20.DRII.LING I,OC attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESC ON color,6ardnea soilfrock tym wain eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks fL ft.
It. tL _
4.Date Well(s)Completed:J- Well ID#
fL fL
5a..Well Location: It. ft.
1'�l'I DfA/Russ �PI�'1• R. R.
Facility/OwnerNa//e Facility WN(ifappticable)
Zino�J Aka r.l'4.A 1/�Gi� ft. fL
PPrEIVED
Physical Address,City,and Zip 21.REMARKS
Aarje" 7 72776/y/Y
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1' y
(if well field,one lat/long is sufficient) 22.Certification:
N w tS t �S-0 -oval
Signature oftertified Well Contractor Date
6.Is(are)the well(s): HPermanent or ❑Temporary By signing this form,1 hereby certify that the wells)%us(were)constructed in accordance
with ISA 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 ❑lam 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 nature of the
repair under#21 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 11.2 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �0 (ft.) Division of Water Resources,Information Processing Unit,
ifwuter level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6.25 (in.) 24b.For Injection Wells ONLY: In addition 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
13a.Yield(gpm) 61 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholdte well construction to the county health department of the county where
13b.Disinfection type: Amount., yt'De� constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water{Resources Revised August 2013