GW1--03439_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:
Bill Kenrled 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name ad ft /t 0 ft a an
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR LINER if iO ble
FROM I To DIAMETER I THICKNESS MATERIAL
Kennedy Well Drilling 0 ft I It 16.25 " 1 SDR-21 PVC
Company Name 16.INNER CA G OR TUBING(eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. In.
List all applicable well permits fl.e.County,State,Variance,Injection,etc.) ft. ft in.
3.Well Use(check well use): 17.SCREEN 1,
Water ply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
gdcultural ❑Municipal/Public ft. ft In.
❑Geothermal(leating/Cooling Supply) []Residential Water Supply(single) % ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑ non 0 ft 20+ ft Bentonite Hydrate chips in place
❑Monitoring ❑Recovery tt ft
Injection Well: ft it
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
-20.DRILLING LOG attach addlttonal'sheets if necessa "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color,hardness,soil/rock etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) ft. ft.
4.Date Well(s)Completed:L.�-- ( Well ID#
o ft.
5a.Well
gLocation: �,,�q �
I/ r t
fC'U/,i G-e, 1iS ft J ft _
Facility//OwaerName Facility ID#(ifapplicable) ft ft rn' ' ` , '
T6 �.�:.� s t � t ,d
/.2[j �L�d� / ft. ft.
P/hysiicfal Ad sss,CLty,and Zip '41.REMARKS '>:.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long its sufficient) `a a ?
�3S�'&73 ;0 f N - 7q/f(X/ 7zi9 W (3�J
Signatur6okeriffled 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 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EK. copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of thisform. 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 ifnecessary.
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: �(01S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdif/erent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
ff ivater 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) C)O Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount• y 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