GW1-2022-09095_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1a.WATER ZONES
Billy Kennedy FROM .TO DESCRIPTION
Well Contractor Name It. It.
2834-A rt. ` D ft. qapsA
NC Well Contractor Certification Number 15.OUTER CASING for mu wells OR LINER it applicable
FROM TO DIAMETER THICKNESS MATERIAL
ft
Kennedy Well Drilling ft• 6.25 , in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
O��/��� FROM TO DIAMETER THICKNESS MATERIAL
Well Construction Permit#: W)!/'/ ft. R. 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 SIZE THICKNESS MATERIAL
❑ fr. g, in.,
Agricultural ❑M�tmicipal/Public
❑Geothermal(Heating/Cooling Supply) - O'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 It- 20+ IL Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. [t.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM I To DESCRIPTION color,hardness,soiVrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft ft. Q
it. ft.
4.Date Well(s)Completed:$ 1 -DZWell ID# ft.
5a.Well
+Location: It' ft.
It. ft. F7
Facility/Owner Name Facility lD#(if applicable) IL iL
16 13 A4 A I f%� /YA ft. ft. 5'f P t) �
Physical Add s,City,and Zip 21.REMARKS
County Parcel IdentificatioT No.(PIN) v t
51).Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N Rr ; —,?I`�o�o`
Signature o rtified 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 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 e1Vo 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and @100) construction to the following:
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 Injection 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)_15'_ 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:
granular hypocholrite Amount: Z�� well construction to the county health department of the county where
constructed. f ':
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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