GW1-2022-09094_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bill Kennedy 14.WATER TONES
y y FROM TO DESCRIPTION
Well Contractor Name 0 ft ft.
2834-A AS- ft. Z15-11. aC
NC Well Contractor Certification Number 15.OUTER CASING formal' ed wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling O IL 1 1,3 fl- 6.25 in. SDR-21 PVC
Company Name 16.INNER CAS G OR TUBING(geothermal closed-loo
^J� 1 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: W�,' dZ7�� fL ft. In.
List all applicable well permits(i.e.County,,State,Variance,Injection,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIT£ THICKNESS MATERIAL.
ft. ft. In.
L1Agricultural ❑M icipal/Public
❑Geothermal(Heatin Coolin Supply) esidential Water Supply ft• ft 10.
� g PPY PPY
01ndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fL 20+ rL Bentonite Hydrate chips in place
Non-Water Supply We11.
tL ft.
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO MATERIAL I 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 FROM I TO DESCRIPTION color,hardness,soWrock tvM Wala silt,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks). 10 It• V
ft. ft. ,I•- '
4.Date Well(s)Completed: 9 We11ID# - ft ` - ft r
5 sr
5a.Well Location: : e' ft- air fL C
�i1✓C e-5, 1{^L41 fa tc
Facility/Owner-Name �- Facility ID#(ifapplicable) ft. ft, _
17ap, AJ t /T 421i ft. n. •��, s����..+ ;Y s id ` v f R
Physical Address ity,and Zip _/ 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: L
(if well field,one]at/long is sufficient)
N W
Signa f Certified Well Contractor 61Date
6.Is(are)the well(s): ofermainent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
�_/ with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or a1Vo 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
S.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 oneform. 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 if dierent(example-3Oa 100'and 1Q100) construction to the following: i
10.Static water level below top of casing: (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 Infection 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
r, I
13a.Yield(gpm) 75 Method of test• Air 24c•For Water Supply&Injection Wells:
/ Also submit one copy of this form within 30 days of completion of
13b Disinfection type:
granularhypocholrita Amount: well construction to the county'health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Watelr Resources Revised August 2013
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