GW1-2023-01901_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Bill Kenned 44 WATERZONE-&--. 3.
Y Y FROM TO DFSCREMON
Well Contractor Name tt. C ill. I
2834-A 'L
NC Well Contractor Certification Number 5:OUTEWCASING form edwells OR LINER 9fa' ileable "
FROM TO DIAMETER THICKNESS AiATERi t
Kennedy Well Drilling 0 ft. ft. 6.25 ;I' SDR-21 PVC
Company Name 161INNEItCAS G.ORTURING e6therz6Id6sed400
t—^1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 44� ft. fL In.
List all applicable well permits f.e.County,State,Variance,Injection,etc.)
3.Well Use(checkwell use):
A7.SCREEN*,-:-:...,
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft. m.
❑Geothermal(Heating/Coohug Supply) Of esidentiel Water Supply(single) ft. ft [n
❑Industrial/Commercial ❑Residential Water Supply(shared) `:18 GROUT:::r . :r ::::.: "::
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ini ation 0 R• 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well:
ft, ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND'IGRAVM-PACK if" liable
❑Aquifer Storage and Recovery El Salinity Barrier FROM ft. To ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control
20:DRII;LING I:OG attach additional sheets itnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardy saWrock t3Te,grain size,etc
❑Geothermal Qkati#giCooling Return) ❑Other(explain under#21 Remarks ft. It. '
ft. ft
4.Date Well(s)Completed: Well ID# .90
ft
5a.Well Location: It-
low,
- ar_ ft. ft a�..o
Facility/OwtARame Fa 'tyID#(ifapplicable) ft. ft.
b 3S— l,ael A,ZZ fL ft. t - 2
Physical Address,City,and Zip
County Parcel IdentifrcationNo.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W —E �� !
Si C tified well Contractar Date
6.1s(are)thewell(s): 21fermaneut or ❑Temporary By signing this form,I hereby certify that the well(s)wow(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an exlsdng well: ❑Yes or 21qo- copy of this record has been provided to the well owner.
ydds is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or an 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: I construction details. You may also attach additional pages if necessary.
For multiple h jection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: L � (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of using: `��S~ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Marl 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 ctmstruction to the following: 1'
(i.e.auger,rotary,cable,direct push,etc.) ' I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm)��{,� Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forms within 30 days of completion of
granular hypocholrite well construction to the county health(department of the county where
13b.Disinfection type: Amount: J�A�
constructed.
Form GW-1 North Carolina Department of Environment andNatut-A Resources—Division of Water Resources Revised August 2013
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