GW1-2022-05891_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 I DESCRIPTION
Well Contractor Name ft. ,I)e". (y
2834-A rt. l/ ft. o
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS JATERIAL
Kennedy Well Drilling rt. rt. s.2s "'• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-lor
/ FRONT TO DIAMETER THICKNESS MATERTAL
2.Well Construction Permit#: ,2 `OO1�/937 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. f[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 29esidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑ non 0 rr• 20+ ft Bentonite Hydrate chips in place
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO MATERIAL EMPLACEMENT'METHODer ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. k.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rack typc rain sit,ctc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) LIP
ft. R.f[. R.
4.Date Well(s)Completed:-/ -a"JAvell M# '
5a.Well Location: a�
ft.
"
.J't�..�17't% 1-f'CI:t.(/iiCl rIItY1,.5�Gvt(J
Facility/Owner Name Facility ID#(if applicable)
_ /•?"-it j.
�_ e/B11 a /[J!/e,-I, L A/ ft. ft. Get.ti.
Physical Address,City,and Zi
/ 21.REMARKS QT .",R)
%'aIL,4n /j k 's 6
County Parcel Identification No.(PIN) L•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W
O
ryry-�,.a �C
s
- Signatu Certified Well Contractor GI Date
Per 6.Is(are)the well(s): (dmanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 L11Vo copy of this record has been provided to tire well owner.
If this is a repair,fill out known well construction information and ecplain the nature of the
repair under#21 remarks section or on the back of this fora. 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,),oil can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(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,
If water level is above casing,ruse••+•' 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) � 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:�2fq well construction to the county health department of the county where
constricted.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013