GW1-2023-02785_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD For Internal vse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Keened A4::WATERZONEs
y y FROM TO. DESCRIMON
Well Contractor Name `j ftAce
2834-14
NC Well Contractor Certification Number IS.-OUTER CASING for multi' ';wens OR`LINER-(Ifa " able)
FROAI I TO DIAMETER I THICKNESS MATEMAL
Kennedy Well Drilling ft. ft- 6.25 In SDR-21 PVC
Company Name "1 :INNER CASING OR TUBING(geothermal closed400
�,•®,/!� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �lPf-'7`7 ft. ft. is
List all applicable well permits fl.e.County,State,Variance,Injection,eta) ft_ ft. in.
3.Well Use(check well use): 17;SCRFFN
Water Supply Well: FROM - TO DLOIETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/public ft ft in.
❑Geothermal(Heating/Cooling Supply) R%(esidential Water Supply(single) ft. I' in.
❑Industrial/Commencial OResidential Water.Supply(shared) -18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation p 1`4 20+ ft- Bentonite Hydrate chips.in place
Non-Water Supply Well
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL.PACK if a Ucable) ?:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEnTDfETHOD
t't. ft.
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG attach additional sheets d'necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRH'TION color,hardnes suftoeh type,grain sire etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 121 Remarks ft. 3 ft. _
\ ft. ft. e��
4.Date Well(s)Completed-\y?"X- Well EN iC !t.
/7 9 4 e-
5a.Well Location: ft. G IL
&tl-VA 1`t h Aaoze, ft. ft.
FacilityiOwner Name Facility ID# ifapplicable) ft. ft.
ft. ft.
Physical
Address,
.wCity.
.,a Ad Zip =21:REhIARKS'
County Parcel Identification No.(PIIN; ll'iC•irt:e::Il 'I;_' ". ;'' Lr.i1
Pd}!.^':roe.•.
5b.Latitude and Longitude in degrees/ndnutes/seconds or decimal degrees: 22:Certification: v
(ifwell field,one ladlong is sufficient)
N wA143'-,20` 3
Signature 2Vertified Well Contractor Date
6.Is(are)the well(s): Ofermanent or ❑Temporary ,By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Ci1Vo copy ofthis record has been provided to the well owner.
Ifthis 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 weds constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or iron-wafer supply wells ONLY with the sane construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /50 (ft.) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths if different(example-3@200'and 2Q100� construction to the.following:
10.Static water.level below top of casing: �.� (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In:addition to sending the form to the address in
rotary 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:
(i.e.auger,rotary,cable,direct posh,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636'Muf Service Center,Raleigh,NC 276994636
y� Air 24c.For Water Supply&Iajeetion:,Wells:`^
13a.Yield(gpm) �J Method of test: - a
Also submit one copy of this'.forty-Aithm.30 days of completion of
gramtlar hypo well well construction to the county h'ealtli department;of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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