GW1-2022-08011_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 FR WATER ZONESOM TO DESCRIPTION
Well Contractor Name Old
ft.
2834-A ft. fa
NC Well Contractor Certification Number 15.OUTER CASING for multi used wells OR LINER if o livable
FROM I TO I DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft _3 ft- 16.25 In. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
/' !� FR011f TO DIAMETER THICKNESS i1MATERIAL2.Well Construction Permit �7#: O�V- V 0000- Cp b ft ft. in.
List all applicable well permits(i.e.Counn,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
ft. ft. In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Qites�idential Water Supply(single) ft. ft. in.
❑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. [L
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FR011I TO DESCRH TJON color,hardy soi)/rocJc in s1w,etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ft.
,v �,^^ ft. It.
4.Date Well(s)Completed: ! - iVell ID#
YU
R. ft. �
5aa.Well Location: f R. ft.
L�111 1 h� �r Ci r1�'�f ft. ft. - -,`ter •:�T,,-.^.,i
Facility/Owner amc,,,9�- Facility ID#(ifappGcable) R. ft.
6I3 1 LF/1 nC!/yKll Le-l tit d ft. ft. I r
Physical Addre. ,CZ,and Zip 21.REMARKS
County Parcel Identification No.(PIN) J:i' 1 i017
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Signam' o Certified Well Contractor Date
6.Is(are)the well(s): 0Krimanent or ❑Temporary By signing this form,I hereby certify that the rvell(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 Imo copy of this record has been provided to the ivell owner.
Ifthis is a repair,fill out knoivn well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthisform. 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 ifnecessary.
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 ifili erent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If}vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013