GW1-2023-02898_Well Construction - GW1_20230418

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennedy ` 4.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name 0 ft. C/5 % ff '-'h
2834-A NO ft.. o�a ft. d7kot'K
NC Well Contractor Certification Number 15.OUTER CASING(for'urulti ed wells OR LINER if ap ltcuble
FROM TO DIAMETER TffiCKNESS MATERIAL
Kennedy Well Drilling % ft. 6.25 SDR-21 PVC
Company Name 16.,INNER CASING OR TUBING(geothermal closed-loop),
/���)/`) /� � FROM TO DIAMETER TMCKNESS MATERIAL
2.Well Construction Permit#: -10` 2 13 —'O o 7" ft. ft. in.
List all applicable i4vil permits(i.e.County,State,Variance,h jection,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS DIATFurar.
[]Agricultural ❑M ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) €7Residential Water Supply(single) ft ft. in.
❑hrdustriaUCommercial ❑Residential Water Supply(shared)
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&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 ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. tL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary'"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ON(color,hardness Wwroek t size,etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: #-/, --Q3 Well ID# ft. fL
ft. al�
Sa/.�Well Location: it. - ft. (..
I U/`E A s �Ol�l . ft. ft.
Facility/Owner Name'-*' Facility ID#(if applicable)
/3a (NjL'S "OP &I ft. ft
Physical Addrefis,City,and Zip ?
V �
�"` �S 7� IO�iJS© 21.REMARKS,,--, ,�.�;1•::3.)L� ,
Q
County I Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one hat/long is sufficient)
N W -
Signature ert fled Well Contractor Date
6.Is(are)the well(s): ermanent 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 2 copy of this 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 421 remaks section or on the back ofthis 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 ifnecessary.
For multiple bdection 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-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: J (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 Iniection Wells ONLY: Iu 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 276994636
13a.Yield(gpm) / Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type:
granular hypocholdte Amount: /tl well construction to the county heal)h department of the county where
!!/�/1_�
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013