_Well Construction - GW1_20230315 (20)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
.14.NVATER ZONES ' 7.
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name <ft. O 0 IL �B
2334-A ft. it-
J .
NC Well Contractor Certification Number 15:OUTER CASING for multi-eased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft- 1 ( ti- 16.25 1 SDR-21 I PVC
Company Name 4&INNER'CASING ORTUBING: eothermaldosed-loo'
^ FROM TO DIAMETER TIHCKNESS MATERIAL
2.Well Construction Permit#: low �Oa"Prot ft. ft. in.
List all applicable well pennits(i.e.County;Slate,Variance,Injection,etc.)
ft. It. In.
_3.Well Use(check well use): 17:SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) Gdeesidential Water Supply(single) tot. ft. to.
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT':
FROM TO MATERIAL EArPLACEMENT itfETHOD&AMOUNT
❑Irri*ation 0 tt 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
it ft.
[]Monitoring ❑Recovery
Injection Well: - - lt• R•
❑Aquifer Recharge ❑Groundwater Remediation 119.SAND/GRAVEL PACK(if licahle)
EMPLAC
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft- ft. MATERIAL EMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control.
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color hardness,soillrockt e s eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft it. I„
". ft. i r . `s
4.Date Well(s)Completedi—rO-43 Well ID# Aje%J s�V0 ft /.
Co ftc [Sa.Well Location: 0 ft. "^
Fauility/04cr Name Facility ID#(if applicable) ft. ft M a\ a v LC Z
ft. ft.
i�•
Physical Address,City,and Zip '21r REMARKS`
7740e/ Y9 ;•�;
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
N W —Ziff glX
� Signature Certified Well Contracto Date
6.Is(are)the well(s): evermanent or ❑Temporary By signing this form,I hereby certify that the uO(s)-was(were)constructed in accordance
� with I5A NCACA2C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Zgl,o ropy of this record has been provided to the xrll owaer•:
(this is a repair,fill out knoivn well construction Information and explain the nature of the
repair tinder#21 rernar•ks 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 h jection or non-water supply ivells ONLY Wilt the sarne.construction..you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: air (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: (ft.) Division of Water Resources,Information Processing Unit,
Ifwarer 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.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 276994616
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
13b.Disinfection type:
granular hypocholrite Amount well construction to the county health department of the county where
Q�r
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013