GW1--03435_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 1F�RO EATER ONES 'TO DESCRIPTION
Well Contractor Name -5-ff
it.
rt. D
2834-A ft. ft. j
NC Well Contractor Certification Number 15.'OUTER CASING`"for multi-cased wells OR LINER if a"" Itcable
FROM TO DIAMETER THICKNESS MATFRiAi.
Kennedy Well Drilling 0 ft oeV ft. 16.25 fir SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(eothermal closed-loon)
-7 7 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: - ar`>a�_ (il�t/�! t'3 ft. ft. in.
List all applicable well permits(t.e.County,State,Variance,Ir#ection,etc)
ft. ft In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑M �ipaUPublic
❑Geothermal(Heating/Cooling Supply) RL'f esidential Water Supply(single) ft. ft io.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EA[PL.ACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 20+ it- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM ft. IL IA To MATERIAL EMYLA CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
fr. rt.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional'sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIP ON color,hardness,soilfrock n s etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. ft.
0q_ ^ q ft 'v' ft. l'r,
4.Date Weil(s)Completed: ell ID#
5a._Well/Location: Lee,
j� ft. ft
/
-R w/ end L.ee, /s OCA ft. ft
Facility/Owner Name Facility ID#(if applicable) MAY 1 S 2023
/ 7 ft. ft.
UL/ G 7 d"l"/ -e S Ar ft. ft.
PhysicalAddr ss,City and Zip 1_
21.REMARKS -;r• i- �,�
O
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W r
Signature ertified Well Contractor 61 Date
6.Is(are)the well(s): 0 rmanent 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 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Belo 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 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 if necessary.
For multiple h#ection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: f�� (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: 1�10 (ft.) Division of Water Resources,Information Processing Unit,
1f 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: 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: 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) 0 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount: 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 Water Resources Revised August 2013
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