GW1-2022-09105_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 T/O� DESCRIPTION i
Well Contractor Name Q R e,2-
2834-A R' ft.
NC Well Contractor Certification Number 15.OUTER CASING for molti cased wells OR LINER If a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft a1 ft• 6.25 1D SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
3�7,5 FROM TO DIAMETER THICKNESS MATERW
2.Well Construction Permit#: f, ft. in.
List all applicable well permits r.e.County,State,Variance,Injection,etc.) fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
ft. TO
❑Agricultural ❑Municipal/Public
�� ft. R.
❑Geothermal(Heating/Cooling Supply) i <.Iidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rri ation 0 It. 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well: It. ft.
❑Monitoring ❑Recovery
Injection Well: ft.
R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R, R,
❑Aquifer Test ❑Stormwater Drainage ft. R•
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soDtrock qM grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks fL R.
4.Date Well() Ps Com leted: � a-Qql�-Well ID#
R.S
ft.
5a.Well Location: fL
Facility/Owner Name Facility ID# ifapplicable) it, fL
1iC3� (
rG ft.
{ni.;1'•? ,�:
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latnong is sufficient)
� Signatu Certified Well Contractor � ate
6.Is(are)the well(s): 01 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 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0< copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known ivell 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:
/ 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
j SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: a/� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing: I z (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _� Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite O well construction to the county health department of the county where
13b.Disinfection type: Amount: constructed.
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Form GW-I North Caroline Department of Environment and Natural Resources-Division of Water Resources Revised August 2013