GW1-2022-09103_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
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1.Well Contractor Information:
14.WATERZONES
Billy Kennedy i
FROM TO DESCRIPTION
Well Contractor Name R. &V ft. IN iPQ
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2834-A R. rt.
NC Well Contractor Certification Number 15.OUTER CASING for rout wells OR LINER if a licable
FRO TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling R ' R- 6.25 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fJ // CX/ fa ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft• it. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. In.
❑Agricultural ❑M�unicipaUPublic
❑Geothermal(Heating/Cooling Supply) 2�Residential Water Supply(single) R. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rrri ation 0 ft- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. iZ
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R•
❑Aquifer Test ❑Stormwater Drainage
i4 R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTIO (cotor,turdne soiLreck type,itmin fits etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R 47 R. AXtAll
4.Date Well(s)Completed: ,,d�'�Well ID# R. rL
Fa.Well Location: ft. 7)7 it.
ft. fL
Facility/O ner Name Facility 1D#(if applicable
ft. R. -' v 6JI-A� �l t� ft. rt. >>
Physical Address,Ci nd Zip 21.REMARKS
A&Ie, g�s� ` -
County Parcel Identification No.(PIN) Ini vi ":� %f; .' U fi
5b.Latitude and Longitude in degreesiminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
Signature f erti led Well Conitactor Date
6.Is(are)the well(s): HPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)it-as(it-ere)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 QNo copy ofthis record has been provided to the well owner.
If this tr a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back ofthis 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 ivith 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 twits list all depths ifdifferent(example-3@200'and2@100) construction to the following:
10.Static water level below top of casing: g (ft.) Division of Water Resources,Information Processing Unit,
Ij'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 rthis form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(Le,auger,rotary,cable,direct push,etc.)
Division of Water Resourees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) At Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypochol6te ^^t� well construction to the county:health department of the county where
13b.Disinfection type: Amount: tat D
constructed. �
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013