GW1-2023-01763_Well Construction - GW1_20230223

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells'
1.Well Contractor Information:
Billy Kennedy 34:WATER-ZONES,:' •.
FROM TO DESCRIPTION
Well Contractor Name ,20 ft. ft. .
2834-A 1t. fL
NC Well Contractor Certification Number 35:OUTER CASING for mul sed-wells OR-IiI M a lieable
FROM TO DIAMETER TffiCKNESS MATERIAL
Kennedy Well Drilling ft. 11il ft. 6.25 lII SDR-21 PVC
Company Name 16.INNERCASING;011TUBING' 'eothermaldosed=loo `.
FROM TO DLAMETF.R THICKNESS ^I MATERIAL'
2.Well Construction Permit#:"T �Yp ft, ft
List all applicable well permits(i.e.County,State,Variance,Injection,etc,) & it in
3.Well Use(cheekwell use): 1'17:'SCREEN? a
Water Supply Well: FROM TO F 1 DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public & M 1O
°` ft. ft. 1n.
ElGeothermal(Heating/Cooling Supply) esidential Wafer Supply(single)
❑Industrial/Commercial ❑Residential Wafer Supply(shared) '.iSrGROUT r`1.:. ,- » ,e '..;••.`t;,>. ;: >•-.'..',:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑on- ate ft' 20+ it- Bentonite Hydrate chi In lace
Non-Water Supply Well: � Y � P
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation %19.,SAND/GRAVELPACK(lfa il6ble
J.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM - TO I MATERIAL EMPLACEMENT METHODft. ft. I
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control It, it
20:DRII:LING LOG.attaeli additional sheets It necessa :' "'"' �, -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solllrock"~type,mmin 4',e(c.)
❑Geothermal(Heating(Coolin Return) ❑Oilier(explain under#21 Rema&s) 0 ft. '3 ft
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4.Date Well(s)Completed: ,-19 a Well ffi ft. ft rjd„# t, S✓fL f
5a.Well Location: d it
a ft. fL
Facility/Owner Name Facility ID#(1f applicable) {t, ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN) +err ri r c;,.l . i Z"-ezvng Gn:1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat(long is sufficient) -
N 1'l' � 4
Signatuce(9t'CertiFi-d Well Contractor Date
6.Is(are)the Well(s): l rmanent or ❑Temporary By sighing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Constuction Standards and that a
7.Is this a repair to an existing well-., ❑Yes or $1 o copy of this record has been provided to,the well owner.
#'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 nudtiple ti jeetion or non-water supply wells ONLY with the same construction.you can
submit one form, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Ili (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij•dierent(example-3@200'aiu(2@I00� construction to the following:
10.Static water level below top of casing: (R,) Division of Water Resources,Information Processing Unit,
#'water level is above casing use"+ --T 1617 Mail Servlt a Center,Raleigh,NC 27699-1617
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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: ry construction to the following:
(ie,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a:Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this Jfb6n within 30 days of completion of
granular hypocholrite well construction to the countyhealth d artment of the coon where.
13b.Disinfection type: Amount: � ep county
constructed
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Waf ler Resources Revised August 2013
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