GW1-2022-10770_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
The form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy fxoM m Drscly noN
Well Contractor Name R ti tl
2834-A ft I R.
NC Well Connector Certification Number 15.OUTER CASING for 7!'W wdb ORLINER 11 tleabk
FRO TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a 6.25 SDR-21 PVC
Company Name 16.INNER CASING ORTUBINC eother7alclosed-1
DIAMETER TInCKNF55 MATLRGL
L Well Construction Permit#: IL R- In.
Lin,all applicable Hell permitr ft.e.County,State,Yawner,lnjeean,Mr.)
R. R. in.
3.Well Use(check well use): 17.
Water Supply Well: FROM TOI DI.o. E R I SWTSITE J THIC-KNM MATERIAL
OAgricultural ❑�MunicipsVPublic 0. it la
OGeothemtel(Heating/Cooling Supply) AResidential Water Supply(single) R R d.
❑lodustrial/Commercial OResidential Water Supply(shared) t4 GROUT
PROM i TO MATERIAL I EMPLACEMENT METHOD k AMOUNT
Chrization Non-Water Supply Well: IL
R• 20+ R- Bentonite Hydrate chips in place
m R-
OMonit,ring ORecovery
injection Well: ft. ft.
❑AquiferRecharge OGmundwater Remediation 19.SAND/GRAVEL PACK ifs 'able
1ROM TO NAiERLU. PMPWC¢MFM M¢TROD
OAquifer Storage and Recovery DSelinity Banner R it.
OAquifar Test DStormwater Drainage
DExpennumal Technology OSubsidence Control
20.DRMLING LOG imarb Mditioulabeeto H necessary)
DCseothermal(Closed Loup) ❑Tracer DIOM TO DESCRIPTION color,We W rule Wm ene
DGeothermal (Heating/Cooling Reuun) 110ther ex lam under#21 Remarks "L h CkLv
7
/
4.Date Well(s)Conglleted:u- /7-`�-WeD ID# R h yrt
Sk `L 0 "
Sm.Well Location: R- R
Ale Xof,1d -Q hula—r1i1 % %
Facditv:o%Mr Namc Facility IDa(ifapplicnble) ft. M1 b ZRZ
�a L-IS Aq Ie1/ /VLL ft. R. D_
Physical Address,City,and#T -
11,REMARKS
dip JOtA �3y�a8'3
Caunty _T Parcel Identification No.(PrN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one loNong a sufficient) '',,
N W '6 ��` olk
� gigmtoozpfCertified Well Contractor Dare
6.Is(are)the weU(s): QPermsnent or OTemporary 0y signing Mir form,1 hereby cerrijy Mar the xrU(,) lasreJ cambumrd in acamd.
rink 13A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard,and Mat a
7.Is this a repair to an existing well: OYes or 34 mpy efMtr record Am born provided o the.11 oaae,.
if ph.is a repair,fill oar kaoxn wet/conurucons m/ormanan and eiplam the natum of Me
repair under 421 remark,section or on the back ofMb form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details mr well
S.Number of wells constructed: construction details. You my also anach additional pages if necessary.
Far multiple injection or non-amersupph•w 1kr ONLY with i acme conawam/on.Iron now SUBMITTAL INSTUCTIONS
submu oneform.
9.Total well depth below land surface: _(fL) 24a. For AB Wells: Submit this fool within 30 days of completion of well
For multiple w1h fiat all depths fdifferent(example-3Q200' ..Qa 100•) construction to the following:
10.Static water level below ca ..7
p of casing: 7 (ft•) Division of Water Resources,Information Processing Unit,
of.re,ievel h;above casing,use"+- 1617 Mail Service Center,Raleigh,NC 2 7 69 9-1 61 7
11.Borehole diameter: 6.25 (in.) 24b.For Iuiection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this from within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(i.c.sugar,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
13s.Yield(gpm) W Method of test: Air 24c.For Water Supply&tulection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Distufectlon type: granular hypochointe Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Reviud August 2013