GW1-2022-08008_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 1F4ROM TO•WATER ZONES DESCRIPTION
Well Contractor Name `' ft. 87 fL '."
2834-A DV ft. 3 n. i--i
NC Well Contractor Certification Number 15.OUTER CASING for mu ti-cased OR LINER if a Ilicable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling fL &_ ft- 16.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ll� fit% O f� fi- 11° !x�_ �J
List all applicable well permits(ii.e.County,State,Variance,Injection,etc.)
ft. ft. iia•
3.Well Use(check well use): 17.SCREEN
Water Supply Well- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ENIPLACEMENTMETHOD&AMOUNT
❑hri ation 0 1' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well: _ +
❑Monitoring ❑Recovery rt ft �� `� ail
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
rt, rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,h2rdness,solltrock type,grzin size etc. .
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:dwell ID# ft. 3U
ft ft.
� th�
Sa.Well Location: 1 I- I- f,7 G a 3 2 02 2
.e^ YT'lfaCtII�r n. n. Inir„;,r,Mic� ?r^: a •t
Facility/Owner Name Facility ID#(ifapplicable) Ur`
�7 ��ll � ) i rt. ft.
J v �i'
Physical Address, ity,and Zip 21.REMARKS
County Parcel identification No.(PIN) gorl--- T" 7 I r-
J t
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) �-
N
�,� Signature 6 ertified Well Contractor v Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby certIfy that the ivell(s)was(mere)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: es or ❑No copy of this record has been provided to the well owner.
If tIris 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: 300 (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,
Ifwater 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: 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) 13 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 hypocholdte 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