GW1--03444_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:
Bill Kennedy 14avATERZONEs
Y i FROM TO DESCRIPTION
Well Contractor Name ft ft.
2834-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased-wells)OR LINER if®' l[catile
FROM TO DIAMETER TffiCKNESS MATERIAL
Kennedy Well Drilling ft. i )ff fL 6.25 " SDR-21 PVC
Company Name 16.INNER CASING:OR.TUBING(geothermal closed4do
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Aptft ft. ln.
List all applicable well pennits(Le.County,State,Variance,L jection,etaJ
tt. ft. in. ,
3.Well Use(checkwell use): 17.SCREEN
water—'supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
BAgricultural ❑MunicipaUPublic ft. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FRONT 70 MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri at►on 0 ft. 20+ ft. Bentonite Hydrate chips in place
Non Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: % ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK fa licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it. To iL MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLINGLOG attach:addiHonal sheets itnecessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION c for hardness,solifroek etc
❑Geothermal(Heating/Cooling Rchim ❑other(explain under#21 Remarks)
_I_r ft. fL o
4.Date Well(s)Completed: /1j— Well ID#
ft. fL a�Q
5aa..Well Location: Almond v ft, ft, _
Facility/Owner Name Facility ID#(if applicable) ft, ft. MAY I Q 7
023
ft. ft.
Physical Address,City,an Zip
.. 21:RERiARKS. -=rss.:Cil f:.'�u•t..�. t.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattlong is sufficient) ryry
N WZAI
I `OC3
Signature erti"ed Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that lire 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 0 0 copy of this record has been provided to the uv11 owner.
If this is a repair,fill out known well construction Information and explain the naiure of the
repair under 021 remarks section or at the back of this fonn. 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 canstrucdon. vu can
submit one fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: oZs .S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depilis if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below tap of casing: a5L� (ft.) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Well4 ONLY: In addition to sending the form to the address in
rotary. 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) —157' 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
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013