GW1-2022-10764_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Inimml Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 1MA7ER ONES- EDKW�IEON
Well Contractor Nara R07 2834-A R a RNC WeII Conoactar Cenifiatbo Number MOUTERCASING fordia OR WNER a b4
PROM TO DIAMETER THICKNESS MwTERIAI,
Kennedy Well Drilling Q R a s.2s In. son-zt PVC
Company Name 16.INNER CASING OR TUBING eolbereasl tlaed4
�,rs /q/�� rI PROM TD nlwMErER THICKNESS MATERIAL
2.Wen Construction Permit#: Wal -f/W 061I Sy R R In
Lief all applicable.11 permi0/i.e.Courtly.Scale,Fa unwe,/njecdon,emJ
R R. la
3.Wen Use(check wen use): 17 SCREEN
Water Supply Wen: mom TO OIAMEI'E11 I sLcyrsin ITmCKNPSN MATERIAL
DAgricultural ❑Municipal/Public R R is
OGeothemmal(Hta ting/Coolmg Supply) Q<midentisl Water Supply(single) R R la.
❑NdustrisiVCommeacial OResidertial Water Supply(shared) IL GROUT
FROM TO I MATERIAL EMPLACIM NTMEOIOD&w OUNT
Non•wa nt supply coca: 0 R• 20+ R Bentonite Hydrate chips in place
R R
OMatitoring DRecovery
Injection Well: R R•
OAquifer Recharge OCrroundwater Remediation It.SAND/GRAVEL PACK e
DAquifer Storage and Recovery OSalinity Barrier FROM lYm MATERIAL EAfI'LA[TOIINT aRIHoo
R R
OAquifer Test OStormwater Drainage R ft.OExperimental Technolo ❑Subsidence Control
2L DRB•LING LOG atueY addilbW stuck U ace
OGwihenoel(Closed Loop) OTn cer mom TO DESCRIPTION alum hardatim,wlPaaA Zraindis,aac.
OGeothermal eatin Coo' Return eOther lain under#21 Remarks R. R.
Ii
1 R —� R
4.Date Wells)Completed: JE'2 Z.hyen ID# a3S- it
Sa.Wall Location: R R
Facility/Owner Naar Facility ID#(if applicable) R R.
/3.3(n t/rx:nn fit.0 /U R R. -
Physical Address,City,and zipHF
21.REMARKS
Conn Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/sKends or decimal degrees: 22.Certification:
(if well field,one IsNarg is suRsieaO
N W Ag ice,-S."
�� Siga%uc Certified Well Coauaceor Date6,1s(are)the wen(s): Gil ermanent or DTemporary, gy signing this form,!Meby certify rMt die wed/r/wa/werel cwvtrund in acxrordance
�/ wdth ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Weft Construction Standard,and that a
7.Is this a repair to an existing well: Ely" or UNo ropy ofthis record has been pree ded to the well owner.
If this is a repair,fill out known wall coratructlon information and"plain the nature ofthe
repair under#21 remarks section or on the back ofthi,form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
R Number of wells constructed: _ construction details. You my also attach additional pages if necessary.
For multiple isfecri ve or non-water supply'wells ONLY work the sau a eoasotiaYbn.ym,our,
suhmitoaeform. a0 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a9V (ft.) 24a. For AB Wens: Submit this form within 30 days of completion of well
For multiple wells list all depots ifdifferent(example-3©200'ands�111,11 l0', construction to the following:
10.Static water level below rap of causing: Zl/ (ft.) Division of Water Resources,Information Processing Unit,
If water level is ahatve caring,asa"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Inieetion Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Wen construction method: rotary construction w the following:
(i.e.sugar,rotary,cable,direct push,era.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEELIS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-16.76
13a.Yield(gpm) Zr- Method of test: Air 24c.For Water Supply&Injection Wells:
Alan submit one copy of this form within 30 days of completion of
13b.Disinfection type: prom hypocha its AmounU well construction to the county health department of the county where
constructed.
Form G W4 North Carolina Depmteneat of Environment and Natural Resources-Division of Water Resources Revisd Anton 2013