GW1-2022-08005_Well Construction - GW1_20220830

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 �� , aft. a. r�
2834-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 19 ft• '31 n 6.25 " 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
FRONT TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ®70!7 ft. R in.
List all applicable well permits(i.e.County,State,Variance,byection,etc.) I, I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mun 'pal/Public
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oh-ri ation 0 fr• 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. IL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRonI ro ft.
.MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage IL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sailtrock typc min sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. 3 tt.
4.Date Well(s)Completed: ot: _�22,Wen ID#
5a.Well Location:
ft. UC7 ft.
A I//V t t./5 5J f lr ft. ft.
Facility/O erName Facility ID#(ifapplicable) ft. ft.
14 ft. ft. Aih c
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:
(ifwell field,one lattlong is sufficient)
` r
Signature' citified Well Contract / Date
6.Is(are)the well(s): Rferumnent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
,� with 15A NCAC 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C?No 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 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: I construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. 24r SUBMITTAL INSTUCTIONS
J 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 iftli ferent(example-3@200'and2@1100� construction to the following:
g/
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 Iniection Wells ONLY: In addition to sending the form to the address in
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(gP m) Method of test: Air
24c.For Water Supply&Injection Wells:
r�
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite ,Amount: /Ga well construction to the county health department of the county where
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constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013