_Well Construction - GW1_20230315 (19)

WELL CONSMUCTION RECORD D For lmetnalUsc ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Bill`'y Kennedy FROM TO DFSCRInION
Well Contractor Name ft. �56 n 'll
2834-A It. —IL
NCWe1lContractorCertificationNumber 15.OYJTEId'CASYNG form wens ORLINER 1fa livable
FROM TO DIAMETER TffiCKNFSS MATERIAL
Kennedy Well Drilling 0 ft• ft 6.25 in SDR-2g I PVC
Company Name 16.INNER CASING OR.T nING eother al elowda
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#- rsti+ L`uc 9 � & fL In
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
ft tl. in.
3.Well Use(check-well use): 17.SCREEN
Water Supply Well- FROM TO DIAMETER ' SLOTSIZE THICKNESS MATERIAL
ft. fL In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) MIkesidential Water Supply(single) ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM I TO MATERIAL EMPLACEMENT IMETHOD&AMOUNT
❑Irri ation 0 fL 20+ f• Bentanite Hydrate chips in place
Non-Water Supply Well:
fie &
❑Monitoring ❑Recovery
Injection Well: fL %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 1f livable
FROM TO ' MATERIAL EMPLACEMENT MEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stomlwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach ad al sheets if necessary
[]Geothermal(Closed Loop) ❑Tracer FROM TO DFSCREMON color,hiadness,soNrack tMe,graLn s etc.
❑Geothermal(Heating/Coolin Return) ❑Other( lain under#21 Remarks) �' It. &� ft. -
ft.
4.Date Well(s)Completed: r �`3 Welt ID# /
ft. IL arA e t
Sa.Well Location:
/J-;�Q t'.�+�I ICP If]�2S �a'_�.5�''l.i�Cdp it. ft. IFS '�'•'�`:,.�i,`may:.,a ct's .,.,_...
`Faadifty/Owner Name Facility lD#(if livable) fL AR
A eA �� ft. ft. 11 L
physical Address City,and Zip --'
' l 21.REMARKS
County ParcelldentificationNo.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Sigttamr- f Certified Well Conuacte Date
6.Is(are)the well(s):21fermaneDt or ❑Temporary
By signing this form,I hereby certify that the well(s)uas(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 eAsthag well: ❑Yes or 27 o copy of this record has been provided to tine well owner.
ydifs is a repair,frlt out known well construction information and explain the nature of the
repair under 421 remarks section or an 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 ifnecessary.
For multiple b jeerion or non-water supply wells ONLPwhh the same construction,you can
submit one form. SUl3WTTAL INSTUCTIONS
9.Total wen depth below land surface: il).S� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Informaiion Processing gait,
If water level is above casing,rise"+" 1617.Mail Service Center,Raleigb,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Intectlon Wells ONLY: In addition to sending the form to the address in
f0$a 24a above, also submit a copy of this form within 30 days of completion of well
12.Were construction method: rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergroumd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361biail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: 06,2z _ well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment andNatrral Resources-Division of W ater Resources Revised August 2013