GW1--07736_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1
1.Well Contractor Information: I ,
Bill Kennedy .14:WATERZONES _ -
Y y FROM TO _ DESCRH'TION
Well Contractor Name 0 ft. ?/7 ft `©
U(/ L/ �i t�ij�f�'1
2834-A ft. ft. lJ
NC Well Contractor Certification Number `15.OUTER CASING(for multi-cased wells)OR LINER(If ap'licable) ,'
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling O ft. 3 ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) , .-
�• ry FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (' OJJ{ ft. ft. in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN „
Water Supply Well: FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Munici al/Public
❑Geothermal(Heating/Cooling Supply) 2'esidential Water Supply(single) ft f[ in.
18.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL t Rrar. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft' Bentonite Hydrate chips in place
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
oAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DF,�'CRu�oN(color,hardness,soNrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. l0 ft. d2,-
4.Date Well(s)Completed://-L3 s13Well ID# /Q ft �/^ ft- /J���e �
5a.Well Loc lion: �30 ft. / V'Ass-ft. C7 dC-k
ft. ft. (((���
5 I' !'o A ✓11V I' ft. ft
--
Facility/Owner Name /± FacilityIID#(if applicable)
® ft. ft.
1677 7 A fii(I!yl 61e.kt i(f� •`U► ft. ft. i .0 .(‘ jry+•, 7O?q�
Physical Address,City,and Zip ,r��r7 9�
/j/� i e- �C�Li®��L 7 i1.REntARxs �r ;
Oti�O I I- %•- _.,�i
County Parcel Identification No.(PIN) ! • '. �L'i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W
Signature ern ed Well Contractor Date
6.Is(are)the well(s): lanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCeIC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I31Vo 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
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: /OC^^' (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: as (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
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
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypochoirite 13b.Disinfection type: Amount: ffe r, well construction to the county health department of the county where
constructed. I I
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water I Resources Revised August 2013