GW1--03445_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 :14.WATERZONES 11 y y FROM TO I DESCRIPTION
Well Contractor Name ft. 310 ft.
2834-A ft. rL
NC Well Contractor Certification Number 15.OUTE&CASING for muttl cased;wells ORLINER' :i: llcable)
FROM I TO I I THICKNESS MATERIAL
Kennedy Well Drilling ft. ®& IL '6.25 In- SDR-21 I PVC
Company Name 16.RMR CASING OR TUBING(euthermal cl6sed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 48 47e ft. ft. in.
List all applicable well permits r.e.County,State,Variance,bgection,etc.)
ft. ft in.
3.Well Use(check well use): 17..SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. In.
❑Geothermal(Heating(Cooling Supply) C3Residential Water Supply(single) ft fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) J&GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. fL
❑Monitoring ❑Recovery
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL�PACK if., lfcable
❑A uifer Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL EMPLACEMENT METHOD
q g er t ft. ft.
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20 DRILLING LOG attach itdditional'sheets if neeess•
❑Geothermal(Closed Loop) ❑Tracer FR TO DESCR Ox color,hardness,soiUrock s etc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks tt, 5- ft
al��WellIIJ# D / /.^ - Cl
4.Date Well(s)Completed: ,
rt. ft. /�„
5a.Well Locations: ft �IL
9W A fL
Facil ty/Owner Name Facility ID1111f applicable) ft ft.
70 ft. fL MAY 2023
Physical Address,City,and Zip
z rvi.� ,n f
{n,Gi r`r
County Parcel Identification No.(PIN) v °
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N Wl-a3
/ S gnatu 'Certified Well Coab=w Date
.1 6.Is(are)the well(s): Permaneut or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
__f 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 QXo copy of this record has been provided to the well owner.
If this is a repair,J111 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
S.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: f(R� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftlfferew(example-3@200'and 1@10q construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
#'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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 Wm) Method of test, Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypochol6te Q well construction to the county health department of the county where
13b.Disinfection type: Amount constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013