GW1-2022-10782_Well Construction - GW1_20221208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1 1 1 1
14.WATER ZONES 4,,
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name OU
-Z-1 ft. 74 ft- a-qv M1
2834-A /60' 16 u rt. so^
NC Well Contractor Certification Number A5.OUTER CASING.for mulfl-a*d wells)OR
1111111cable)
FROM I TO I DIAMETER THICKNESS MATERIAL
MATERIAL
Kennedy Well Drilling 0 fl- I Lf'n it 16.25 i In I SDR-21 PVC
CompanyName ',16;INNER CASING OR TUBING:(�661he 'ddsed400p):.-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constrdctiou Permit#: ..Q0aR19n62 W ft. ft. In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREENsi
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS _MATERIAL
ft. ft. In.
13Agricultural OM ' 'pal/Public .
EiGeothermal(Heating/Cooling Supply) =e.Usi,(,lntia1 Water Supply(single) ft ft. in.
oIndustrial/Commercial OResidential Water Supply(shared) -A8.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. R.
OMonitoring DRecovery
Injection Well:
DAquifer Recharge 0 Groundwater Remediation .19.-SAND/GRAVEL PACK ifs nmllcableh,
FROM TO MATERIAL EMPLACE OD
OAquifer Storage and Recovery OSaUnityBarrier ft. ft.
DAquifer Test ElStormwater Drainage ft. ft.
DExperimental Technology 0 Subsidence Control `-,mD G LOG(attach additional sheets if necessary) I
oGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soillrock type�grain sim,etc.)
-75— .
oGeothermal(Hcating;S/ ooling Return) DOther(explain under#21 ft it.W
. - ell iD#3 o ' 1(y ft. "--
4.Date Well(s)Completed: — 1-4 -6-ft• it.
5a.Well Location:
ft-
3-6—� abLS-�r-
C) ft. ft.
Facility/Owner Name I/ Facility ED#(ifapplicable) ft. ft. DEC
!A 10 W& tf(Vv ft. ft. i ni i
Physical Address,City,and Zip
',21.REMARKS':
County L/ Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
N W
-3�AQZk
Signature di Certified Well Contractor C--s Date
6.Is(are)the well(s): M<Qanent or 13Temporary By signing this form,I hereby certify that the well(s)was(were)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: 0Yes or 09.- copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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
S.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 cats
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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.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'Center,Raleigh,NC 27699-1636
13a.Yield(gpin) 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 well construction to the county ihealth department of the county where
13b.Disinfection type: Amount: 0;z constructed.
FormGW-1 North Carolina Department of Environment and Natural Resources-Division ofWater Resources Revised August 2013