GW1-2022-05863_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:
Bill Kenned 14.WATER ZONES
y y FROM TO DESCRIPTION
Well Contractor Name -5 0 ft. a ft. X- C /,`
2834-A 1879 rt. ft. c 1 h
NC Well Contactor Certification Number 15.OUTER CASING for mul' ed wells
O
Kennedy Well Drilling FROM O DIAMETER RTIN a IiM RL
IL ft- 16.25 "' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
�/ / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3�D-3 (� 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. in.
❑Geothermal(Heating/Cooling Supply) ff<idential Water Supply(single) ft. ft. in.
❑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 Iicable)
FROM 'I'O MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. 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 DESCRIPTION color hardness,soul rock t 0. rain sic,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: Well ID# , r Gf
5a.We11 Locaft n:
i`c9i�l Cd y
Facility/Owner Name Facility ID#(if applicable) ft. ft. JUN 1 7 �
771 ���1i77e e tt. b
Physical Address,City,and Zip
21.REMARKS
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)
�� Signatu fCertified Well Contracto Date
6.Is(are)the well(s): !?Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)is-as(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 ❑No copy ojthis record has been provided to the well owner.
If this is a repair,fill out known well constniction information and explain the nature of the
repair under 421 remarks section or on the back ojthis 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: f (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@I00) constriction to the following:
10.Static water level below top of casing: `)D (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 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) 0 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: �y
well construction to the county health department of the county where
�
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013