GW1--03436_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROM
O DESCRIPTION
Well Contractor Name rlli'1ft. a7 ft.
2834-A O��t/ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If a lieable
FR011f TO DIAMETER THICKNESS biATERiAI.
Kennedy Well Drilling t7 fl- J' ft• 6.25 in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(eothermal closed400
FROM TO DL1111ETER I THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Wet Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
IaAgricultural ❑MunicipaL/Public fL ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EDIPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMYLACEDfENT METHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIP ON color,hardness,soil/rockt size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Renuuics ft. S ft.
4.Date Well(s)Completed: d 6`-0aWell ID# ft ao ft (fr t.^f t2
ft. D ft. r ri
5a.Well Lo Hon: it. ft.
rt. rt.
Facility/Owner Name �J�� Facility ID#(if applicable) ft. ft.
�dJ l.?tll�� /�Ut ft. ft. "• f;
Physical Addr s,City,and Zip �'..' n•,°y 4
.21.REMARKS
l rte 7733 992�9a
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: r;i
(ifwell field,one lat/long is sufficient) v o�`Z;'v'• a
N W �G/ r�0/Lt '7 a6-
SignatWof Certified Well Contract Date
6.Is(are)the well(s):•e'Permanent 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fill 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: construction details. You may also attach additional pages if necessary.
For multiple hyeetion or non-water supply wells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: v /� (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'and2@11001 construction to the following:L
10.Static water level below top of casing: 1 V (ft.) Division of Water Resources,Information Processing Unit,
If rvater level is above casing rise••+'• 1617 Mail 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
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: Amount:granular hypocholdte o� well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013