GW1-2022-04950_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD .
For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kenned .14.WATER ZONES
Y Jy/ FROM TO DESCRIPTION
Well Contractor Name ft- ft.
2834-A J00 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mu ti ca wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. ft. 6.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: ����Z ft. ft. DIAMETER
List all applicable well permits(i.e.Count),,State,Variance,Lyection,etc.) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�ricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Su 1 (single) ft. ft. in.
� � g PPY) PPY( g )
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 rt. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft. MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology El Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft. ft.
ft. ft. !
4.Date Well(s)Completed: yla-aZWell ID#
ft. ft.
5a.Well Location: -
fL
Facility/Owner Name Facility ID#(if applicable) MAY 1
l /� / [' /
&VS A/�h � a l r- Sd emay ft. ft. -
Physical Address,City,and Zip
21.REMARKS
I=
r;ra1i"',va•,i i'�
County Parcel Identification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(if well field,one lat/long is sufficient) /`
N W 6;
Signatur fCertified Well ContmctW Date
6.Is(are)the well(s): 01611manent 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 [RNo 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 opt 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
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. r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 0� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 11 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
.•� �- Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount: well construction to the county health department of the county where
/�n S
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013