GW1-2022-08010_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,
14.Billy Kennedy FRONT WATER
FRONT TO DESCRIPTION
Well Contractor Name 1w Z pyl
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
FRONT TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 rt. ' ft. 6.25 in. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: o - 0000Is"Co ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,b jection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mun 'pal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FRONT I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
[]Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FRONT TO 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 FRONT TO DESCRIPTION color,hardness soWrock ty
pe,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. - R. r/ `
/ ft. 30 ft'
4.Date Well(s)Completed:b /3-'Z-Well ID# 40 vo ft. ft.
5a.Well Location: t _
Fac��ilit((y/Owner Nam[�c++ �� Facility ID#(if applicable) ft• ft.
lF
Physical Address,City,and Zip
21.REMARKS "---- :�• '�;�^?:,-�:'t'.. t Ril
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)
N W ®
Signature o rtified Wei Contractor 7 Date
6.Is(are)the well(s): Ofermanent or ❑Temporary By signing this form,I hereby certify that the nell(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 131V0 copy ofthis record has been provided to due well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 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: 1 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 onefonn. 2 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ZoL5' (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 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 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) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
136.Disinfection type: Amount: t t2 constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013