GW1-2022-09097_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:
Billy Kennedy FR WATER ZONES r
FROM TO DESCRIPTION
DESCRIPTION
Well Contractor Name .S f`' aac ft 4
2834-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER If a "licable
FROM TO DIAMETER TIHCKNESS MATERIAL
Kennedy Well Drilling Q rc ft 16.25 in I SDR-21 PVC
Company Name yA�^^ 16.INNER CASING OR TUBING eotherma]dosed-loop)
��OO4DO�/O FROM TO DIAMETER THICKNESS M&TER
2.Well Construction Permit#: Ll�][ ft-
O ft- in. u! _ O
List all applicable well permits f1e.County,State,Variance,Injection,etc.) tL f4 in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SI77E THICIINESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft.
❑Geothermal(Heating/Cooling Supply) E .idential Water Supply(single)
❑ FROM
Industrial/Commercial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft- 20+ fL Benton i a Hydrate chips in place
Non-Water Supply Well: 0 ft /0 ft p
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applicable)
FROM. TO MATERIAL EMPLACEMENT MET HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage fL ft.
[]Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM I To DESC N color,btrduess,sosurock tyM gMn size etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks IL I ft.
^� ft. ft.
4.Date Weil(s)Completed: o(,J ell ID# ft, nn ft.
JAQ
ctfll.7or
Sa.Well Location: ft. ft. t, ' 't�'
Facility/Owner Name Facility ID#(if applicable) ft. ft. _
t , sMS�I!!' �cc)ialnJod
Physical Add s,City,and Zip 21.REMARKS
•u 1 /,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
Sigoa f Certified 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 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lallo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
1 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
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: OCOG 7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: ({f) 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 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
I f
Method of test: Air 24c.For Water Supply&Injection Wells:
13a Yield(gpm) 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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