GW1-2023-01873_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD 1
_ For imemal Use ONi.Y: a
Uis formcan be used for sia;is or multiple wells
s,
1.Well Contractor Information:
Billy Kennedy F
ROM TO .F"M: :;: ;
nrsc tttrmox
'Well Contractor Name 2834-ANC WellCanlractorCertificationNumberTO DL AMICER 77nrrnass MATU".
Kennedy Well Drilling 6 fL6.25 'f- SDR 21 PVC
CompanyNnmcz..wen Construction Permit#*),
(� �/(����1 fL
to o>�i�rEtz TRt �, 1
%
IW an appucable wdl permits fix, variance,rr� etc.)
tt_ R. In.
3.Well Use(check well use):
Water supply wen: FROM I TO I WAMFTM I SLOTSM I 9HICENM ,•MATMAL
OAgricultural O�Mt�micip—a�i/Ptablic ft a,
la
Meothermal(Heating/Cooling Supply) ❑Mdeautal Water Sally(single) R ft in
upP y( )
- ❑Indvstrial'Commcial OResideoaritial WateS 1 shared
FROM I TO MA CEMENT M6 " AMOUNT
01rri on Q to Z0+ M
Eton-Water Supply Well:
fL 0monitoriog ORecovery A.
Injection Well: h- n
❑Aquifer Recharge OGroundwatcrRemediation 29; 3r$l;Re►fYG
OAquifer Storage and Recovery CJSaliuity Barrie FROM To MAT 0".L t3[nPI ACaP1SlYr MEMOD
n. ft.
OAquifer Test 0Stormwater Drainage
Ct. R.
OExpertmentalTechnology OSubsidence Control :7A DA113t[!G ', aidi shtzitiD"
l7Geothermal(Closed Loop) OTraeer FROM TO DESCRU ON tutor h-ftfts,wnrrmt, ci.)
OGeothermal tin Cool' Return Mother(explain under#21 Retnodcs f
4.Date Wen(s)Completed: "0 • WeIIID# %
53.Well1AMAIti(M. M
Faciliryl�vaeeNaau T! Facility JD#(if ap liable) r� u
.) iz
2 ft.
Physical Address,City,and lap
county pmcclidcntiftdonNa..(PlN)
t4, ? Clrr,
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees;
22.CerdoC8H00:.
(ifwell field,one k0ong is sufficient)
r
W 1-a3 a 3
� Sigoauac o fi Well Contractor Date
6.1s(arse)the weU(s): of"romanent or OTemporary �Y signing ,faro,,1 hereby ca*duct die xWO)use,(were)conrnucred in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and chat a
7.Is this a repair to an existing well: Dyes or UK copy ojAw reeved ba:been provided ro the welt owner.
Ifthis!s a repair,j711 out known well cansnucdox tnfannattat and eaplatn the nature nitre "
repair under#21 remarks section or on the back ofthisfornt. 23.Site diagram or additional well details:
You may use the hack 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.
Par multiple injection or nun-tinter supply wrlis ONLY whh the sane aonw ncSon,you can {
submir ane form. SUBMMAI,INSTUCTIONS '
9.Total well depth below land surface: 020,5— (ft.) 24a.For Au Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if&Terent(erampfe-3W00'and 2Q100� construction to the following:
10.Static water level below top of casing: _ (jl-) MvMon of Water Resources,Information Processing Unit,
/'Water level is abave casing,use"+" 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (ia.) 24b.For Infection Wells ONLY: 'In addition to sending the form to the address in
24aabove,also submit a copy of;tbis form within 30 days of completion of well
12.Wen construction method.rotary construction to the following:
(Le,auger.rotary,cable,direct pctsb,eta) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test•Air 24ta For water Supply&injection Well,
Also submit one copy of this form within 30 days of completion of gnmular ��
13L Mainfectlon type: Amount well construction to the county health department of the county where
consuwed.
Facer(7W-1 North Carolina Department of tinvitomaml and,lattual Resources—Division of Water Resources Revised August 2013
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