GW1--05277_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name /(g0
f• /1 r-ft �n M
at(_j
2834-A 010ft. [ ft. //�
rA
NC Well Contractor Certification Number 15.OUTER CASING(for multi ed wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 3 If ft• 6.25 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
� 7� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: [�' ft. ft. in.
List all applicable well pennits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural OMunicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Qential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft ft.
0 Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
:Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. CO/ ft. O ri
4.Date Well(s)Completed: 7- 13 Well DO 6 ft. I5- ft. ,s k Acl IC
I - ft. Ws,
ft.
t lleyrot^
5a.Well Location: j ft. ft.
lfieL Fal�s Are sit,�+'7.e ClotlfccI ft. ft. •.--...
Facility/Owner Name Facility ID#(if applicable) ft. ft. L`'ti°"'( f r'r I- ,',.:,
alp? 6/g✓It,L4 -Ca el-k� ft. ft. AUG 1 Z. ?O?3
Physical Address,City,and Zip 21.REMARKS
if frcore 11i r,7;ccsc.r1 ?rn:ss4.r.'3 Ur,b
County Parcel Identification No.(PIN) Iiv- .30'..a
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) O
N w ,U� j<P�z/.Y� 7 13`-a3
Signature erti ed Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certifr 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 121<_ copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction ittfornration and explain the nature of the
repair under 1121 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. J!� � SUBMITTAL INSTUCTIONS -
9.Total well depth below land surface: O (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'and 2@100') construction to the following:
10.Static water level below top of casing: 5c2S*-- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6'25 (in.) 24b.For Infection Wells 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) t Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite ��1 well construction to the county health department of the county where
13b.Disinfection type: Amount: t Oep
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013