GW1--03406_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROMATERz ONES DESCRn'rtaN
Well Contractor Name ft. ft.
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If a licable)'
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0tt. - D.- ft. 16.25 la• I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i/� ft. ft.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
ft,
ft. in.
3.Well Use(check well use): 17."SCREEN
Water Supply Well: FROM TO DL111JETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Reating/Cooling Supply) Eftte­sideutial Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ fl• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft ft.
❑Monitoring ❑Recovery
Injection Well: ft. f4
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.
To MATERIAL I EMPLACEMM METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional'sheets ifnecessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON color,hardness,soittrock s' etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. It*
ft. ft.
4.Date Well(s)Completed: 7 t3 Well ID# s
ft. 30 .60e1'A
ft. t rt-e-
Sa.Well Location:AA:Q-eA4411 holy
Facili Ownr Name Facility ID#(if applicable)
t
ft. rr. MAY 171 2023
*I
�� �t g5(- 'd/'a(Cc„ram .S ft. ft. t
Physical Address,City,and Zip .�
21.REMARKS lilt r+++^u'
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)
:3S*�s' --) N 7 7, W - -�3
� Signature Werth ed Well Contractor Date
6.Is(are)the well(s): C�TPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 4JSVo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
i You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple it jectimt ot•non-water supply wells ONLY with the same construction.),on can
submit one form. 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 d(ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 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
13b.Disinfection type:
granular hypoeholrite Amount: ll�� well construction to the county health department of the county where
/t2� constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013