_Well Construction - GW1_20230315 (18)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
t
1.Well Contractor Information:
Billy Kennedy FRO CATER TONES DESCRIPTION
Well Contractor Name ft. / ft.
2834-A rt. / rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
FROTf TO DIAMETER THICKNESS 11L1TERLII.
Kennedy Well Drilling 0
ft. I (o ft• 16.25 SDR-21 PVC
Company Name M INNER CARING OR TUBING(geothermal closed400
�/� FROM TO ' DIAMETER THICKNESS MATERIAL2.Well Construction Permit#:=a `190 �00 ft. ft. in.
List all applicable hell permits�.e.County,State,Variance,Ljection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
g Supply) Supply(single)
it ft. in.
❑Geothermal(Heating/Cooling Coolin Su 1 esidential Water Su 1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri=ation 0 it- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer StorageFROM TO and Recovery ❑Salinity Barrier it. ft. MATE1dAL EMPLACEMENT METHOD
❑Aquifer Test - ❑Stormwater Drainage
ft. Tt.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solllrock type rain siic,etc.
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) ft. ft. o)-
VIN
4.Date Well(s)Completed{ - Well ID# ft. S _ `!f-
5a.Well Location: - ft. _ ft. C
/'/��/ iW• AJ<eA Zt1Pi ft. ft
Facility/On erName Facility 1D#(if applicable)
ft
��y . ft.
377L�r �> !14 eG,r L/I 1'�/K/ �� ft. ft. MAR i i n L
Physical Address,City,and Zip 21.REMARKS
7 9 VT t• ;j
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 1 W ,6 �e 3 -7-a3
/ Signat�Certified Well Contractor Date
6.Is(are)the well(s): PSPermanent or ❑Temporary By signing this form,I hereby certify that Cite 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 W copy of this record has been provided to the well owner.
#-this is a repair,fill out known well constrtction,it formation and explain the nature of the
repair under#21 remarks section or on Cite back ofthis 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 byeetion or non-water supply wells ONLY with the same construction,you can
submit one form. Q SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this;form within 30 days of completion.of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Iflater 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
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(gpm) 3 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 health department of the county where
13b.Disinfection type: Amount: ��dt� constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013