_Well Construction - GW1_20230315 (22)

WELL CONSTRUCTION RECORD For Internal Use ONLY-
This form can be used for single or multiple wells:
1.Well Contractor Information:
Bill Kelliled :14.
WATER ZONEs
y Y FROM TO DESCRIPTION
Well Contractor Name GLJ ft• ftaq
2834-A it ft.
NC Well Contractor Certification Number15:OUTER'CASING_fortnnlH=caseii.weUS OR LINER''if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling D ft. .6.25 In. SDR-21 PVC
Company Name 16.INNER CASING OR.TIJBING('eothermid clased466
_^� FROM TO. DIAMETERHI THICKNESS MATERIAL
2.Well Construction Permit#: 0� ; =O �O�I� ft. fL Ia
List all applicable ueUpermits(i.e.County,State,Variance,Injection;etc.)
ft ft: in.
3.Well'Use(checkwell use):
Water-Supply.Welh - - - _ FROM TO DIAMETER sLOTSVE THICKNESS MAiL ft.
TERIAL -
El Agricultural OMunicipal/Public 1n
❑Geothermal(Heating(Cooling Supply) QKsidential Water Supply(single) ft. ft.
❑Industrial/Commercial DResidential.Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 it 20+ ft Bentonite Hydrate chips in place
Noa-Water Supply Well:
ft ft.
❑monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAVEL PACK if a livable
❑Aquifer Storage and Recovery [:]Salinity Barrier FROM TO MATERIAL EMPLACEdffiNTDiETHOD
tt rt.
OAglliferTest OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 20 DRIIJUNG LOG attach additional'sheets if neces§n'•
❑Geothermal(Closed Loop) ❑Tracer FROM ILTO DESCRIPTION(color,hardness,sa rock fte,grain size,etc.,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft- &f ft
ft ft•
4.Date Well(s)Completed:a`071718 Well ID# 46/• !l1/L
5a.Well Location:
(i obb v ft. ft.
Facility/Own Name Facility ID#(if applicable)
G9 a t v ft ft.
T^—
Physical Ad City,and ' 21i REMAIIKS;
oh A 76 yVllfG 95-1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N 7?.*Y4j.1q' w i d/-l 3
Signa�Certified Wetl Contractor Date
6.Is(are)the well(s): Wermanent of ❑Temporary By signing this form;,I Hereby certify that the wells)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or OIVoo copy of this record has been provided to the well owner.
if dds is a repair,fill out known well construction information and explain the nature of the
repair under 421 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:. _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 2@100) construction to the following:
Division of Water Resources,Information Processing 10.Static water level below top of casing: fs (ft.) g Unit,
Yivater level is above casing,use"+^ 1617-Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
rota 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 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a® Method of test: Air 24c.For Water Supply&Injection_Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type-
granular hypocholrite Amount: well construction to the county health department of.the,county where
Gz
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013