GW1--06188_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennedy 14:-WATERZONEs , ,.4,�.
Y Y FROM TO DESCRIPTION
Well Contractor Name /O ft. l a ft. , s i 10 e
2834-A ft. ft.
NC Well Contractor Certification Number f15.OUTER CASING(foi mult1.cased wells)OR LINER(if ap licable),-
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft io ft. 6.25 !• ' in. SDR-21 PVC
Company Name 16 INNER,CASING.OR TUBLNG(};cottierinalclosed loopsi'_. ., . bh,,1. .,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 87s9 ft. ft. 1 •
, in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL s.
ft. ft. in.
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT,m..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft. /0 i S
Injection Well: ft. ft S
❑Aquifer Recharge ❑Groundwater Remediation .:19.°SAND/GRAVEI3PACK;(rf applicable) _[ ',
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
ft. ft. ;'
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology ❑Subsidence Control 20;'DRILLING•LOG(attach:additional.sheetSilfnecessary);, ..
❑Geothemtal(Closed Loop) OTracer FROM TO DION(color,hardness,son/rock type,gain size,etc.)
❑Geothermal(Heating/Cooling Return)t DOther(explain under#21 Remarks) ® ft 3 ft. 1„1-
4.Date Well(s)Completed:a a, -.2 Well m# 3 ft. /s- ft Aa�/eL -dirt
p/--ff. ^A� ft. /�/`/oc-k
5a.Well Location: !J ft. 9W ft. ��lC�
545 0I.11 A s n,c ft. ft.
Facility/Owner Name Facility BM(if applicable) -
ft. ft. @ h �
k— .,'3..:. sir.. },a,Li
76-6 sunset h'Jfs ft ft
Physical Ad ,and Zip r'.._ fW; O h;, j::=��2�„y
.-21RE1GIARRS ,_
CJACOLAL?el/ 3e3 9 Ili z.z? r" <-:^ r J 4
County Parcel Identification No.(PIN) Dr`u i.ir'Yi r✓
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) t ;
Signature ertified Well Contractor 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 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C3'No 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 j
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
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9.Total well depth below land surface: 903 (ft.) 24a. Far 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: 60 (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 Injection Wells ONLY; In addition to sending the form to the address in
24a above, also submit a copy of tliis 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(gpm) Method of test: Air 24c.For Water Supply&Injecti`n Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite /�Z 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
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