GW1--03437_Well Construction - GW1_20230518

WELL CONSTRUCTTON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kenned 14.wATER:zoms.
Y Y FROM TO I DESCRIPTION
Well Contractor Name ft. o fL
2834-A ft. %
NC Well Contractor Certification Number 15.OUTER CASING for mulh-cased:wells .O L Rif a lieable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 0 it. 6.25 in SDR-21 I PVC
Company Name 16.MNER CASING'OR TUBING('eethernial closed-loo
•� FROM TO DIAMETER THICKNESS bATERIAL
2.Well Construction Permit#: a0a0Q_01X0a�/7 ft. fL in.
List all applicable well permits r.e.County,State,Variance,Injection,etc.)
it. ft. in.
3.Well Use(check well use): 17 SCREEN, '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
ft ft. in.
❑Agricultural OMunici al/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft.
18:GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ;;19:SAND/GRAVEL L PACK if a` livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. fL TO MATERIAL I EMPLACEMENT bfETHOD
❑Aquifer Test ❑Stormwater Drainage tt. ft
❑Experimental Technology ❑Subsidence Control
`20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESc Ox color,hardness,soiltrock type,grain size,etc.`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. J ft. Ad.-CJAV
4.Date Well(s)Completed: well m# ft. �^�it. &v n- F
ft. '5-5- ft.
5a.Well Location::T It. i ` 15_ft.
Ja m-e 5 I/ l!e�' ft. ft.
Facility/Owner Name FacilityID#(ifapplicable) ,
nn rb //!� •�, ft. ft y . it.N f
ft. ft.
Physical Addr sLl
y-and Zip
21:RE1vfARIt5 �
7743��17��
County Parcel Identific� (PIN)
No.(PI 1n iC+� s -m
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one tattlong is sufficient)
N w
SigaaWi6hfCertified Well Contradd Date
6.Is(are)the well(s):•111ermanent 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 ❑No copy of this record has been provided to the well owner.
Ifthis is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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 ii jection or non-water supply wells ONLY with the same construction.you can
submit one form. ^^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: aLoC� (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@100D construction to the following:
10.Static water level below top of casing: � (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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) _ 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
I .