GW1-2022-05849_Well Construction - GW1_20220617

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 s'9 ft. ft. r
2834-A /S' rt. ft.. 7
NC Well Contractor Certification Number 15.OUTER CASING for mult' ased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling l" ft. 6.25 in. 1 , 98/: 6 f/o.si;ze
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
e FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: // ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Ejection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Munic 1/Public
❑Geothermal(Heating/CoolingSupply) esidential Water Supply ft. ft. in.
PP y) PP y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 20+ rt' Bentonite Hydrate chips in place
Non-Water Supply Well:
tt. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO MATERLAL EMPLACEMENT METHOD
er ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTI(N color,hardness,soiltmek type,gnin sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. �0 ft. C
4.Date Well(s)Completed: -OCJ-�G ell ID# 30
ft. ft.
5a.Well Location:
/ l ft. Ct.
Facility/Ow rr NName/ Facility ID#(if applicable)
Physical Address,City,and Zip 21.REMARKS
lawcwLc-P, 2-7�ZZ/70Dl
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi tion:
(if well field,one lat/long is sufficient)
N W aS=o?�o2a
Signature F ertified Well Contractor Date
6.Is(are)the well(s): Oferinaiierit or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�" with 15.4 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 QNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of[he
repair under#21 remarkr 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
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 call
submit one form. SUBMITTAL INSTUCTI JNS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) a 0 Method of test: Air 24c.For Water Supply&Injjection Wells:
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: 1-?
-� constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013