_Well Construction - GW1_20230315 (23)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROM TO DESCREMON
Well Contractor Name too % -'*L% IGO rh
2834-A R. It.
NC Well Contractor Certification Number I CASIN00i*V1d%,welh,OR 1&NM(if a�e):,
FROM TO 1 THICKNESS 1 MATERIAL
Kennedy Well Drilling U4 ft- :L<—a, It- 16.25 1'- 1 BDR-21 I PVC
Company Name 16.INNER CASING;ok:
2.Well Construction Permit#: FROM fL TO ft. DIAMETER In. THICKNESS
MATERIAL
List all applicable well permits(I.e.County,State,Variance,ly#ection,etc.) ft ft.
in
3.Well Use(checkwell use):
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
It ft DAgricultural OlviunicipaVPublic I I I -
%
DGeotheimal(Heating/Cooling Supply) UA-Qdentil Water Supply(single) ft.
Oladustial/Conimercial DResidential Water Supply(shared) :'19.',GR0UV:�:;
FROM TO MATERIAL EMPLACEMENT IMETHOD&AMOUNT_
DIrrigation 0 ft' 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well: fL %
13Monitoring DRecovery ft.
Injection Well: tt
OAquifer Recharge OGroundwater Remediation SAND/GRAVEL PACK'(Napplicable),-.
FROM TO MATERIAL I EMPLACEMENT METHOD
DAquifer Storage and Recovery OSaUnityBarrier ft. It.
DAquifer Test 118tormwater Drainage11. ft.
OExperimental Technology 0 Subsidence Control .20.DRILLING LOG'attaeh additional sheets If ueiressm�)%
OGeothermal(Closed Loop) OTracer FROM I TO DESCRIMON(color,hardness,saftfrock tMe,grain sizv,etc.)
DGeothermal(Heating/Coolie Return) 00ther(explain under#21 Remarks) "" ft.
ft-
ft
4.Date Well(s)Completed: —oV—Q3 Well 1D# ft-
<"-ft ft
-
5a.Well Location. it. L01 57
ft.
ft.56,iczL It ft
Facilit 10w= ft. ft.
. Name' Facility ID#(if applicable)
ft. ft. WAR
Physical Ad ss'City,and Zip
41.REMAIM:
M 7-A570991
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) &I
Signature 6l'Certified Well Contractor Date
6.1s(are)the well(s): Rfermanent or DTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A MCA C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or 2mo— copy of this record has been provided to the well owner.
If thisis a repair,Jill out known well construction information and explain the nature of the
repair under#21 remark 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 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 if different(example-3@200'and 2@100) construction to the following;
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 20.For Infection 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 276994636
Air 24c.For Water Supply&I
13a.Yield(gpm) Method of test. jnection Wells
Also submit one copy of this f6tm within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
13h.Disinfection type: Amount: ez — constructed. I
Form GW-1 North Carolina Department of Environment andNatuml Resources-Division of Water Resources Revised August 2013