GW1-2022-05892_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 0-5
tt. 1 d5 ' tK ant
2834-A Wt- ft. a "
NC Well Contractor Certification Number 15.OUTER CASING for multi-caseA ells OR LINER if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling fL L ft. 6.25 ' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
61
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �f/ � (1�n11 (OCfJ ft. ft. in.
List all applicable well permits r.e.County,State,Variance,bjection,etc.) -
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRO51 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu 'al/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rr. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO er (t. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG(attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sim,etc.)
El Geothermal(Heating/Cooling Re-turns) ❑Other(explain under#21 Remarks) ft. ft.
ft.
4.Date Well(s)CompletedL�O/J+ ell ID# o R.
ft. It. e P9 e-k-
5a.Well Location:
A"J
Facility/Own/er Name � Facility IID#(if applicable) fL ft.
/
Physical Ad City,and Zip 21.REMARKS _
d �,)10 7777.)'1q 0,?q
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 ��
Signatu Certified Well Contractor L Date
6.Is(are)the well(s): E�lPermanent or ❑Temporary By signing this form,I hereby certify that the xell(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 2Ko- copy of this record has been provided to the well owner.
If this 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:
l You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: d construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: al (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,
If water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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
(gp m) Air 24c.For Water Supply&Injection Wells:
13a.Yield (� Method of test:
Also submit one copy of this foss within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount: �0z
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013