GW1-2022-05854_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.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name O5It- ft.
2834-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling rt. 02 ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
G '7 FROMM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: D 9�l R. R. in.
List all applicable well permits(i.e.Couniv,State,Variance,Itjection,etc.)
ft, ft, in..
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑�Mun-icipal/Public
❑Geothermal(Heating/Cooling Supply) rf esidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ ft- 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 a livable
❑Aquifer Storage and Recovery []Salinity Barrier
er ft. TO ft. MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil'tock type min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft, q ft. 0.
/ ft. rt. 1&6ks
4.Date Well(s)Completed:..?-19 Q-7 Well ID#
ft. ft.
5a..�Well Location: rt. ft.
ca
U- Lwiie-
Facility/Owner Name Facility 1D#(if applicable)
a q a G say l�� S G,do/ ,erg ft. ft.
Physical Address,City,and Zip
` 21.REMARKS
County Parcel Identification No.(PIN) "' nv^,f)i;;; i;✓'l,i..!7 `"v 1�t""
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient)
P
N W ;, 'j
Signature of ifQ Well Contractor Date
6.Is(are)the well(s): UrPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 5K copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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
8.Number of wells constructed: / construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
/
9.Total well depth below land surface: ,f (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if eli f event(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: as" (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 24aabove, 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) ICL Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: 07 well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013