GW1-2022-08007_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This torn can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATERZONES
FRODI TO DESCRIPTION
Well Contractor Name /�/7 It- /e S ft.
2834-A
NC Well Contractor Certification Number 15.OUTER CASING(for multhea 6d wells OR LINER if a licable
FRO1 TO DIAMETER THICKNESS MATERIAL
KPnnPriy Wgll f�rillinn i7 rc. _J/J rt. a�5 in. CI�R_21 p�1r
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS 'MATERIAL
2.Well Construction Permit#: L(}/VJ fr• ft• in.
List all applicable well permits(i.e.Coun State, Variance.Iniec•tion,etc.)
ft. it. in.
3.Well Use(check well use): 17.SCREEN
Wate upply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
ft. ft, in.
gncultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. fc.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FRONT TO MATERIAL EMPLACENJENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tr. tc. /F^
ft.
4.Date Well(s)Completed: �0-1aWell ID#
ft. ft.
5/^aI.Well Location: 1 J Jt tc. fc.
i1/tt/1C�1/J9�1 V— :�l Kt L7i�1L(.)%1 ft. ft. ^•, `t' o `t y" y�
Facility/Owner Name /J Facility ID#(ifappiicable) ft ft
ft. ft. AUG 3 l LL
Physical Address,City,and Zip 21.REMARKS jr r j
U{� , ,J
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)
Stgnatu o ertitied Well Contractor Date
6.Is(are)the well(s): Ofermanent or ❑Temporary By signing this form.i hereby certify that the well(s)u•as(were)constructed in accordance
n•ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ETAlo copy of this record has been provided to the srell ox-ner.
If this it a repair,fill out knoua 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
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wit n the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �L�J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example and 22@100� construction to the following:
10.Static water level below top of casing: VL7 (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
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
m 13a.Yield
(gp ) C� Method of test: Air 24c.For Water Supply&Injection Wells:
l,�
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 of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013