GW1-2022-04083_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name D ft ft- �d M
2834-A SSe". a6-/ ft
NC Well Contractor Certification Number 15.OUTER CASING for mul' wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling jo ft 56 ft 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 7�sty S ft ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft ft m.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 D- 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage [t ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiltrock type,grain siiP,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a
ft ft. C
4.Date Well(s)Completed: 3-3 ` Q-2wa ID# 6- ft S.S ft i6f N 4 /t 0
S" ft. 0 ft
5a.Well Location: ft ft,
A AA �
�1i�/r�✓1 l�. J"`a rd u to ft a! ft
Facility/Owner Name �- Facility ID#(if applicable)
It. ft
90K ,Mn QIr_ S'ad-"SS ft ft
Physical Address,dty,and Zip
21.REMARKS
Ghaf k.a M
County Parcel Identification No.(PIN) APR
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) I1�)ry
N qt vatiL
Signat6gofCerfified Well Con or Date
6.Is(are)the well(s): 20-1r1anent 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 Illy; 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 oneform. SUBMITTAL INSTUCTIONS,
9.Total well depth below land surface: 110-4- (ft.) 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 2@I001 construction to the following:
10.Static water level below top of casing: S110 (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: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
rotary
24a above,also submit a copy b f f his 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 m Air 24c.For Water Supply&Injection Wells:
(gp ) o� 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013