GW1-2023-02894_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATER ZONES ,
Billy Kennedy .FROM TO DESCRIPTION
Well Contractor Name ft. ft.
a`yl
2834-A
NCRrellContractorCertificationNumber 1 OUTER'CASING forrirultt' ivells,.ORLINER ifn llcable
FRO•I TO1 DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft- ft 6.25 in. SDR-21 PVC
Company Name -16:-INNER CASING OR TfIBING geothermal dosed loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 4 7W ft. ft. In
List all applicable wellpermits(i.e.County,State,Variance,Injection,eta)
ft. ff: in.
3.Well Use(check well use): -. 1 SCREEN
Water Supply Well: FROM I TO. DIAMETER SLOT SIZE THICKNESS I MATERIAL
ft ft, In.
❑Agricultural ❑M cipal/Pubhc
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single). ft. fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) '.18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f• 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft, M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and,Recovery ❑Salinity Barrier ; ft. ft.
[]Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20rDRII1.INGL0G.att2ehaddtt[onalshcets'Ifuecessary
❑Geothermal(Closed Loop) ❑Tracer FROM I TO. .. DESCRIPTION color,hardn saWrock tym grain size,etc
❑Geotbmnatl(Heatin Cooling Return) ❑Other(e lain under#21 Remarks) A ft- ftrin
%
4.Date Well(s)Completed:3"�Well ID# it it
Soo.Well Location: l ft? .1%
A
Facility/Owner Name Facility ID#(if plicable) ft
� of ft. ft. APR 1 s 2073
Physical Addre s,City,,nnd Zip :'21 REMARKS
County Parcel IdcndficationN6.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/fong is sufficient)
N W l�o v k _ 3 -A&`20
Signature MOertified Well Contractor Date
6.Is(are)the well(s): O ermanent or ❑Temporary By signing this form,I hereby certrfy that the 4,ell(s)was(were)constructed in accordance
with 73A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Y.es_ or RWo- copy ofthis record has been provided to the well owner.
If 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
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. ) SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ! (ft.) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifditjerenu.(example-3@200'and s2@100� 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 27699-1617
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: rotary construction to•the following:
.(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Prograny
FOR WATER SUPPLY WELLS ONLY: 1636 Mail.Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 610 Method of test; Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
granular hypochotrite a� well construction to the county health 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