GW1-2022-05897_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:
B111 Kenned 14.WATER ZONES
y y FROM TO DESCRIPTION
Well Contractor Name {-81, ft. &X ft. al,
2834-A ft• / f!(".
NC Well Contractor Certification Number 15.OUTER CASING for i iulti-chff6d wells OR LINER if a licable
FROM TO DIAMETER THIC[NESS MATERIAL
Kennedy Well Drilling ft. S.- ft. 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
J ^t'1 _��0����0 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: r/��gyp( ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h'ri 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 licable)
FROM 'CO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck tv c rain siu,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. It. Qf m'l`Ve ,/-
4.Date Well(s)Completed: etl ID# It - R b
5a.Well Location: ! !�
J
Ga/'Ql ��
Facility/OwnerNamee Facility ID#(iifapplicable)
q Il /Jet,4 ,t y� d Gk(.1-1A
Physical Address,City,an Zip
21.REMARKS
/'vry �l,��. < <o 12 a6,15-60
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) / /
�� Signature ertified Well Contractor Date
6.Is(are)the well(s): ET ermanent or ❑Temporary By signing this form,I hereby certify that the tvell(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 [21 o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and erplain the nature of the
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 if necessary.
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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@a 200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rotary 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) 30 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount: well construction to the county health department e county t of the where
8►Z
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013