GW1-2023-02891_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
.Billy Kennedy FROM TO DESCPJMON
Well Contractor Name ft a if, ft.
2834-A D;fr. faWT
NC Well Contractor Certification Number
15::OUTERCASING tormuffi d.w ORLINER a "llcablel
FROM - TO DIAMETER P THICIQHE.SS.-- .MATERIAL
Kennedy Well Drilling fL ff ft 16.25 in1 SDR-21 PVC
Company Name ;&EMNEWCASING OR TUBING; `eothermal`closed=loo' `
FROM" TO DIAMETER THICKNESShfATERIAI
2.Well Construction Permit#: .��pQO�j NQ % ft in
List all applicable well permits 0.e.County,State,Variance,Infection,etc.) g• ft In
3.Well Use(check well use):
17 SCREEN„
Water Supply Well: - FROM TO DrAMETER SLOT SM THICKNESS I nIATERUL
fL
❑Agricultural ❑Mu ltP nicipaublic " ftln.
❑Geothermal(Heating/Cooling Supply) R09idential Water Supply(single) In
❑Industrial/Commercial ❑Residential Water Supply(shared) 18"GROUT
FROM TO MATERIAL EMPLACEMENT MSIHOD&&MOUNT
❑Irri ation 0 1- .2o+. .ft Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwalerRemediation ,19:SANDIGRAYELPACK-.(tta"7lcuble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEDiEN r METHOAF
ft, ft:
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:'DRIILING:LOG:attach'additiowal'sheets. necessa "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRI TION color,hardnes soll(rack tym grain d-z etc.
❑Geothermal(Heating/Coolin Return) 00ther(explain under#21 Remarks). . . R•" ft
ft. fL
4.Date Well(s)Completed:3'01 'Q3 Well ID# it. ft
5a.Well Location: 14y ft. S ft
Makwn_. ,G ft. ft
Facility/Od'ner Name. Facility lD#(if applicable) -
ft. ft
.7%3.1 0e' nAl fC! 1/I lit'' it. .. .. "t_... ..
Physical Ad s,City,and Zip
21 3tEMARKS -
AIA
7 tQ
County Parcel Identification No.(PIN) 4rt;�,
5b.Latitude and-Longitude in degrees/minutes/seconds or.decimal degrees: 22.Certification:.
(if well field,one latflong is sufficient)
N W afel t
� Si�ture 1 Ce ied Well orrCactar�� Date
6.Is(are)the well(s): rXI'ermanent or. ❑Temporary ' By signing this form,I hereby certtyyr that the well(s)was(were)constructed in accordance
�� with 15A,NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conshvction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z1. copy of this 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. A 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 ifnecessary.
For multiple iq jecaom or non-water supply wells ONLY with the saute construction,you cal
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple:wells list all depots if different(example-3@200'and 1@100.1 construction to.the following:
AZA
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above cuing,,vse"+" .1617 Mall Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection.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:
(i.e.auge,rotary,cable,direct push,etc.).
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636.Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) a2 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: Amount:
granular hypocholrite g 'well construction to the county health department of the county where
. e� ,
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013