GW1-2023-01258_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
,M WATER ZONES
Billy Kennedy FROM TO DESCRUqION
Well Contractor Name ft fL
2834-A AK& ft.
15..0UTER CAAS1nNK(:for1mAW-t' Wells) aliplicabli)
NC Well Contractor Certification Number rl 0 FROM TO DIAMETER -rwm Eklp 91AATERit�ALL
Kennedy Well Drilling ft- 22 ft- 6.25 "- 1 SDR-21 I PVC
Company Name '16.INNER'CASINGrORTUEING
.(pe I otherm,.al cloted[4001�1-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: "?0/ fL fL in.
List all applicable nwil permits ri.e.County,Stat.4 Variance,bjection,etc.) ft. IL in.
3.Well Use(checkwell use): 17 .. i .
SCREEN:.' --d
Water Supply Well: FROM
To DIAMETER SLOT SIZE THICKNESS MATERIAL MATEIGAL
DAgricultural DMunicipal/Public ft.
OGeothermal(Heating/Cooling Supply) 26'sidential Water Supply(single) ft ft
01adustrial/Commercial EIResidential Water Supply(shared) _18AMOUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Elltrigation 0 ft 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: fL ft.
OMonitoring DRecovery Injection Well: It. ft
(
OAquifer Recharge 11 Groundwater Remediation 19L'SAND/GRAVEL.PACK if
FROM TO I MATERIAL EAULACLNIENT METHOD
OAquifer Storage and Recovery 0 Salinity Barrier ft. I
DAquifer Test 11 Storrawater Drainage
DExperimental Technology OSubsidence Control
[]Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,bardaess,sontrack t)pe,grain etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. aft. CJ0
4.Date Well(s)Completed: Ca.11 ID# fL a-46—ft.
% ft.
5a.Well Location: ft. ft.
J1"k!Q --f ft. fL
Farility/owner Name Facility 1D#(ifapplicable) ft. ft.
ft. fL
7a3 S kvete-& ChE V JAN 2 7 2023
Physical Address,City,aJ Zip
.RENIARKS:­. .'�::��
urlft
County Parcel Identification No. N
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat(long is sufficient)N W _192 /a 42 2,
SignaturfffCertified Well Contra[D_ Date
6.Is(are)the well(s): permanent or OTemporary By signing this form,I hereby certify that lite well(s)was(were)constructed in accordance
with 15A NCA C 02 C.0100 or 15A NCA C 02 C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or Zfo copy of thus record has been provided to the isell owner.
#'this a a repair,fdl out known well construction information and explain the nature of the
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: 1 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _(ft.) 24.. For All Well. Submit this form within 30 days of completion of well
For multiple wells list all depths iftlifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: LTO (fL) Division of Water Resources,Information Processing Unit,
#"water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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: AJ r 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholfite- Amount: (11 12P well construction to the county I health department of the county where
constructed.
FormGW-1 North Carolina Department of Environment andNatural Resources—Division of Water Resources Revised August 2013