GW1-2022-09042_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name O o ft 'va ft ' H1
2834-A oluo f`' (` a
NC Well Contractor Certification Number 15.OUTER CASING for mul' ed wells OR LINER i(a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft. 1° ft- 6.25 In SDR-21 I PVC_
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM I TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. I IL in.
List all applicable well permits fl.e.County,State,Variance,Injection,etc.) fL I & In
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS12E THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 20+ it- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 0 applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRW71ON color,hardy soll/roch tv
pe,gmin size etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks IL IL
ft. (� (t. A G Q
4.Date Well(s)Completed: ~a�Well ID# IL 7 ft.
rUl^o t
5a.Well Lo on: a5- f 301 t^-ft- L
Facility/Owner NameeQ __ Facility #(if applicable) ^
/moo Aft ft.
a!3 73 �'I,a fir G'ee(< (t. ft.
Physical Address,City,and Zip 21.REMARKS _ t�
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: y I rUIOG V
(if well field,one fattlong is sufficient)
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Signature o ertified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 a 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: 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
,r� SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface y7�L7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#dierent(example-3@200'and 2@100) constriction to the following:yy
10.Static water level below top of casing: `7 U (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.Foriniectiop 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
Method of test: Air 24c.For Water Supply&Infection Wells:
13a.Yield(gpm) / Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholdta Amount: / e O 2 well construction to the county health department of the county where
constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013