GW1-2022-10786_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:
A 4.,WATER'ZON ES'
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name fiv ft. ft.
ft. �%
'A
2834-A �%44
NC Well Contractor Certification Number 15.OUTER CASING. multi-case nqo%=hpy%�
FROM TO DIAMETER
Kennedy Well Drilling 0 It, ft- 6.25 :"" 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(ge6thermal-dositl-lobp)
of FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 7 ft. ft. in.
List all applicable well permits(1.a County,State,Variance,Injection,etc.) It. ft. in.
3.Well Use(check well use): 17.SCREEW
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
ElAgricultural OMunicipal/Public ft ft.
DGeothermal(Heating/Cooling Supply) Zr.id.ntial Water Supply(single) ft. ft
DIndustrial/Commercial DResidential Water Supply(shared) .18.GROUT- ......
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrri2tion 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
•
[]Monitoring ORecovery
Injection Well: ft• ft.
oAquifer Recharge DGroundwatcr Remediation A9.SAND/GRAVELPACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD-
0Aquifer Storage and Recovery ElSalinity Barrier IL ft.
0Aquifer Test El Stormwater Drainage ft. ft.
OExperimental Technology USubsidence Control
"20.DRILLING LOG'attach additional sheets tfnecessaiy)
Meothermal(Closed Loop) ElTracer FROM TO DESCRIPTION(color,hardness,softock typc rain sin,etc.)
0 Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) ft. I ft•
ft. to ft-
4.Date Well(s)Completed: 123-Well ID# _q
1D.
5a.Well Location: 357 ft- JW-"
160Aot,-e_l ak I I J Colo, fL ft.
Facility/Owner Name Facility ID#(if applicable) It. ft.
ft. ft.
-
Physical Address,City,and Zip 21-.--REMARKS--,"'
Ile- 001002 Ce qT
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if'well field,one lattlong is sufficient) &&
Signature ortertified Well Cofitractor Date
6.Is(are)the well(s): 2We'rmanent or Memporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC.4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or 25-0-- copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the n a hire of die
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
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J& _(ft.) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferen t(example-3 @2 00'and 2@ 100 1 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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
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(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 well construction
Amount: - constructed. I
13b.Disinfection type: to the county 1�eallh department of the county where
Form GW-1 North Carolina Department of Environment and Natural Resources-Division ofWateriResources Revised August 2013