GW1-2022-07182_Well Construction - GW1_20220729

I
WELL CONSTRUCTION RECORD For Internal vse 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
2834-A i+ rt. V0 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mul e&,wells OR LINER tf a Ileable
FROM TO DIAMETER THICKNESS .MATERIAL
Kennedy Well Drilling 0n• ft. 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 0a ? FROM TO DIAMETER THrCKNESS MATERIAL
I OD00IJ ft.
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 ❑�Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) f, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '`18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hn- ate ft. 20+ ft. Bentonite Hydrate chips in lace
Non-Water Supply Well: � Y P P
❑Monitoring ❑Recovery fL ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK it a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO MATERIAL EMPLACEMENT METHODer ft. 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 DESc TION(color,hardness willrock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R• 02 ft. G,
1- 4 ft- 30 ft-
4.Date Well(s)Completed: '-Well ID# O ft- a0rL
5a.Well Location:
� J//1 / ft. ft.
13ra Al Pam/ / i/1-L .. &O OA - 'ft. ft.
Facility/Owner Nime Facility ID#(if applicable) ft ft.
_IIpGG�X �/�a b'�•�,�ae ft. ft. I 9 2Q22
Physical Address City,and Zip 21.REMARKS -
�lQ�lJ/ �DO�i Sr7g �8fbon PrOCWW.g Uno
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)
� Signatui"fCcrtified Well Contractor Date
6.Is(are)the well(s): Q ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
Kith 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 81V0 copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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@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 Injection 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: ry 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) f o2 Method of test: Alr 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: �D D� well construction to the county health department of the county where
constructed.
i
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i I