GW1-2023-02892_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Imemal Use ONLY:
This form can be.used for single or multiple wells'"
1.Well Contractor Information:
Billy Kennedy :14:'AVATER'ZONES
FROM" ". TO DESCRIMON
Well Contractor Name D ft.
2834-A ft. ft 47�'
NC Well Contractor Certification Number 15:=:O11TER;CASING for i "ed well`FOR LINER'ifa llcable)
FROM TO - DIAMETER THICKNESS MATERIAL `
Kennedy Weff Drilling ft. ft. .6.25 h" I SDR-21 PVC
Company Name 16INNER=CASING OR TUBING:_ eothermal'dosed-loo
FROM. TO .DIAMETER THICKNESS bATERIAL
2.Well Construction Permit#: (Jly�r(/ (/ ft ft. , la
List all applicable well permits(I.e.CotmV,State,Variance,Injection,etc.)
ft. ft.. in.
3.Well Use(check well use):
17 SCREEN•,
Water Supply.WeD: FROM TO DIAMETER .SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaMblic It. tt
❑Geothermal(Heating/Cooling Supply) esidential Water
_supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)` '1&:GROUT ,? ;..
FROM TorMATERIAL EMPLACEMENT IMMOD&AMOUNT
❑Irri ation 0" ft. 20+ ft, Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft
[Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 1%'SAND/GRAVEIrkACK ifa lltuble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
n. ft.
❑Agtnfer Test ❑Stotmwater Drainage ft. R
❑Experimental Technology ❑Subsidence Control
Z11-DRILLING'LOG'attach additional sheets if necese'"`
❑Geothermal(Closed Loop) ❑Tracer FROM' TO DESCMUON(color hardness,soWrock etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks), -fL q ft.
ft ft
4.Date Well(s)Completed oE7 Weil ID#,.
rt bao
52..��W��elll Location: M R
,/J Il7011 l5(pJQ er'1 ft. ft
Facility/Owner Name, Facility 11M.fitapplicable). _ ft
�O14W V if Z ft. It.
Physical Address,City,and Zip 21 RE11fARK5:= - p
County Parcel Identification No.(PM
5b.Latitude and Longitude in degreesJmitrut"dseconds or decimal degrees: 22.Certification:
(ifwell field,one lattlong is sufficient) "
N
SignaWf Cettificd Well Comxa Date
6.Is(are)the well(s): ceermanent" or ❑Temporary
By;signing this forum,I hereby certify:that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or. UK, copy ojthis record has been provided to the well owner.
If ibis Is a repair,jilt out known well construction in and explain the nature oftlie .
repair under#21 remarks section or on the back ojthis 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 multiple injection or non}eater supply wells ONLY with the same construction..you can
submit one form. SUB51ITTAL INSTUCTIONS.
9.Total well depth below land surface: (ft) 24a.For All Wells:. Submit this fonri within 30 days of completion of well
For multiple wells list all depths ij'different(example-4@200 and,.@1009. . construction to:the following:
Lin
10.Static water level below top of casing: ((1) Division of Water Resources,Information Processing Unit,
If water level is above casing;use"+ 1617 Maif'Service Center,Raleigh,NC276994617
11.Borehole diameter: 6.26 (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 push,etc.)
Division of Water Resources,Underground,In ecdon Control Program,
FOR WATER SUPPLY WELLS ONLY:. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: Air 24c.For Water Supply&Nection Wells:
Also submit one copy of this forth within 30 days of completion of
granular hypocholdte well construction to the county,health department of the coup where
13b.Disinfection type: Amount:��T)� ty� ep county
constructed.'
Form GW-1 North Carolina Department of Enviromnent and Natural Resources.-Division of Water Resources . Revised August 2013