GW1--07734_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i :
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1.Well Contractor Information:
Bill Keened '14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name J- ft. .$; ft. S
2834-A JO ft. ffa5 it S f
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased/lvells)OR LINER(if applicable) _ . .. . -
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling O ft• 3 eft 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
P Y
I// D� f FROM TO DIAMETER . THICKNESS MATERIAL
2.Well Construction Permit#: N ft. ft. in.
List all applicable well permits(i.e.Cmmty,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use): 17.SCREEN
Water apply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural ❑Municipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft it in.
Oludustrial/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.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL.PACK(if applicable) • '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
of ❑Aquifer Test ❑Stormwater Drainage it. it
❑Experimental Technology ❑Subsidence Control '
20.DRILLING'LOG(attach additional'sheets if necessary),.-- . ,
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/reck type,grain size,etc.)
❑Geothermal(Heating/Cooling ft. ie.•� .
(�Return) ❑Other(explain under#21 Remarks) � ft• /D
4.Date Well(s)Completed: ( �6, ell ID# /0 it a"-f L .6ktsl-0/4{
5a.Well Location: / fi L•G ft. _ ft. �• ; _ , 1
�/1 //WV/ trl'l5 G ft ft err. ;' ?. ...
Facility/ near/Name / Facility ID#(if applicable) ft. ft. •- ') / 2023
/or-&15 n :9-e� /.6/� .D ft. ft. 1.S ,::::;_.:1
Physical Address,City, d Zip T
..21:REMARKS
/folQ0Pe-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) .
N W /� w�fC / /`.94 Signature o ertified Well Contractor i Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
" "•' with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair'to an existing well: ❑Yes or 121Vo 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 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
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 construction,you can
submit one form. ,, ,cam SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (902.S (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 dJ200'and 2@i 00') construction to the following:
10.Static water level below top of casing: /5- (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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: ry construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) 1 '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
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13a.Yield(gp m) 670 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 / well construction to the county hen
department of the county where
13b.Disinfection type: Amount: aQ? constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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