GW1-2022-04117_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ft' ye H' a Arul
2834-A &V ft' olys". t'o iY
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling rL S-� rt. 6.25 ; id SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotherma]closed-loop)
q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . t0 I -000 o aa3 91 fL [I. tn-
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.l
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Csidential Water Supply(single) ft. ft in.
11
❑lndustrial/Commero FR
ial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft- 20+ R- Sentonite Hydrate chips in place
Non-Water Supply Well:
ft ft.
❑Monitoring ❑Recovery
Injection Well: R. ft.
❑Aquifer Recharge ❑GrotmdwaterRemediation 19.SAND/GRAVEL PACK rifapplicable)
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft-
❑Aquifer Test ❑Stormwater Drainage
ft. I ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock tym gnin sir,Ma
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL
4.Date Well(s)Completed: 3-IS-J_a-Well ID# ft
/O` ft. ft �a r r
5a.Well Location: ft. ft.
3ol�n soh _ �en-zT ft. ft.
Facility/Owner Name Facility ID#(if applicable)
7
7212 C2 ft. ft. Q
Physical Address,City,and Zip 21." REMARKS
�/4 4 771173 9,253 7 '
County � Parcel Identification No.(PIN) �� i rt a
N ra
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
N W 6 3-is=a�aOt
� Signature ertified Well Contractors Date
6.Is(are)the well(s): BPermanent or ❑Temporary By signing this form,1 hereby cer*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 2<o 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 thisform. 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 one form. SUBMITTAL INSTUCTIONS
9.Total welt depth below land surface: 305/ (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdii ferent(example-3@200'a(n'd�2@100� construction to the following:
10.Static water level below top of casing: v v (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 On-) 24b.For Iniection Wells ONLY,: In addition to sending the form to the address in
nn 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
139.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
I36.Disinfection type:
granular hypocholrite Amount: e�
well construction to the county health department of the county where
/G
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013