GW1-2023-02895_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:
Bill Kennet ,141;WATERZONES
Y y FROM TO DESCREMON
Well Contractor Name /® ft. i
2834-A ft. ft.
NC Well Contractor Certification Number ;15.:OUTERC TONG-for mDMwAOER f allableL
FROM E
MATERIAL
Kennedy Well Drilling ® ft- 1 &7 ft. 16.25 in SDR-21 PVC
Company Name 16 INNER CASING OR:. ING eothermal closed-loo
�g ® pry ,jr FROM TO DTAnrr't'rR TIDCKI�iESS MATERIAL
2.Well Construction Permit#: aCV�7 (J�t�a �-31/161 ft it lu
List all applicable well permits(i.e.Country,Slate,Variance,Injection,etc.)
ft ft. to
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Publie & fL In.
❑Geotheral(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
m
❑Industrial/Commercial ❑Residential Water Supply(shared) '-,M GKOUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OIrrigation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fL ft.
Aquifer Recharge ❑Groundwater Remediation 19.�SAND/GRAVEL PACK t1fabbileable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft.
[]Aquifer Test ❑Stormwater Drainage
tit. fL
❑Experimental Technology ❑Subsidence Control '2o.'DRD LING LOG attach4ildidbuil sheets If Recess
aryY
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESc ON color,hardness,8o11/roclr e, R etc.
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks ft. ft.
Jea
pp•���� f4
4.Date Well(s)Completed:6 '13 d7 Well En it
!�
ft. ft.
Sa.LWell Location: a- iG
,�Q
urQ el ft. ft.
Facility,XhAcr Name Fac ty ID#(if applicable)
Physical Address,City,and Zip
RE1l1ARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '- }
(ifwell field,one lat/long is sufficient)
SignahuP'' t-erti6ed Well Contractor Date
6.Is(are)the wells): rmanent or ❑Temporary By signing this form,I hereby certify that the wells)14W(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill atit 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 wells constructed: / construction details. You may also attach additional pages if necessary.
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 All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-38200'and 2@1001 contraction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casin&use••+" 1617 Mail 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: rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Q0 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this,fdrm within 30 days of completion of
13b.Disinfection type: granular hypocholdte Amount: a E) � well,construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of We t.,Resources Revised August 2013