GW1-2022-09962_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennet 14.WATER ZONES
i
Y y FROM TO DESCRIPTION
Well Contractor Name IX R. © ft.
2834-A ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS AtATER1AL
Kennedy Well Drilling ' ft' I q,2 ft 6.25 1 'in. I SDR-21 PVC
Company Name 16.DINER VA9ING OR TUBING eothermal closed-loop)
/' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /`�l� ft. ft. in.
List all applicable well pennits(i.e.Coun,y rate,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Wate pply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
gncultural ❑MunicipaUPublic ft, ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 it. 20+ ft- Benton'ite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK it a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAtPL10EMENTAtETHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
[]Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(color,hardness,soWrock type rain size,etc.
❑Geothermal(Heating/Cooling Return) [:]Other(explain under#21 Remarks) it. R.
44 ft. 2( ft.
At
4.Date Well(s)Completed: = Well ID# �J _L
it. ft.
5a.Well Location:
Facility/Owner Name Facility ID#(ifappheable) V
ft. ft. "
ft.
Physical Addre s,City,and Zip
21.REMARKS ..yvu W v^ ,
De 2 4a3OG
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N
.
7�;G>>3 �r��w -�;
Signatu Certi ed hactor ' Date
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6.Is(are)the well(s): RPermanent . 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 02C.0200 Well Consoacfion Standards and that a
7.Is this a repair to an existing well: ❑Yes or QN.- copy of this record has been provided to the well owner.
If this is a repair,fill out knoun well construction information and explain the nature of the
repair under#21 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: l construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you Carr
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: f'�S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdi�'erent(example-3@200'and 2@I00') 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 Iniection Wells ONLY: In addition to sending the form to the address in
rota 24aabove, 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 f nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount
granular hypocholrite well construction to the county health department of the county where
1��1�
constructed.
Form GW-1 North Carolina Department ofEnvircinment and Natural Resources-Division of Water Resources Revised August 2013