GW1--03438_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
14.WATER ZONES. .
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ft. ft. M
2834-A
NC Well Contractor Certification Number 15.OUTER CASING'for-mul sed well4 OR LINER.3f- licdble
FROM TO DIAMETER THICKNESS aATERIAL
Kennedy Well Drilling 0
ft. ft. 6.25 in SDR-21 PVC
Company Name 16.INNER CAS G OR TU$ING fgettiberiiial closed-loop)
� � FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ! �/�// ft. ft. in
List all applicable well permits fl.e Cow Izo;State,Variance,Injection,etc.)
[t. fL in.
3.Well Use(check well use): 17.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS UATERIAL
❑Agricultural ❑Municipal/Public it, fL in.
❑Geothermal(Heating/Cooling Supply) �dential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ie:GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 it' 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. it
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL-PACK(if a li'cable
❑Aquifer Storage and.Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACENIENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets lf recess'
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIMON color,hardness,soa/rock t to sim,eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) ft ft.
ft. ft.
4.Date Well(s)Completed:,.<-,3-a3 Well EM f C
10 It. ft
5a.yWell Location: *.
Facility//Owner Name Facili ID#(if applicable) rr
ft. ft. kr� -pi �SFi .d
n
Physical Adtlre s,City,and Zip
21.REAiARKS I N1CJ.
County Parcel IdentificationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat(long is sufficient) +�
N W �
� Signature f erti red Well Contractor Date
6.Is(are)the well(s): [f1'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 290 copy ofihis record has been provided to the hell owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
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 b jection or non-water supply wells ONLY with the same construction,you can
submit one fornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /&55 (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 j2@I00) construction to the following:
10.Static water level below top of casing: TD 00 Division of Water Resources,Information Processing Unit,
!/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (iu-) 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 Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method oftest• 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: t��Z well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department ofEnvitonment and Natural Resources-Division of Water Resources Revised August 2013