GW1--03849_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FRO`CATER TOSS DESCRIPTION
Well Contractor Name o ft. ft. 7
2834—A ft. ��IL, V o,
NC Well Contractor Certification Number 15.OUTER CASING for,m sed wells OR LINER if a licable) '
FROA1 TO DIAMETER THICKNESS r1fATE n
Kennedy Well Drilling 0
ft• d2 r ft• 6.25 " SDR-21 PVC
Company Name 16.INNER CASING.OR TUBING(geothermal closed-loop)
,., � FROM TO DIAMETER THI
CKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLllVIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) .I�Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 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 applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM ft. To I MATERIAL EMPLACEMENT METHOD
I
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIMON color,hardness,soft/rockt in size,eta
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. t
�G
ft. It. y /�
4.Date Well(s)Completed:�7 ° Well ID# ljr R. ft.
5a...Well Location: ft. ft.
L"U.L w l/f�l ��5k-v ft. ft. J U N
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
q'7' Gf/ Ad ft. ft.
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W
Signature iLDCertifled Well Contractor Q Date
6.Is(are)the well(s): 2fermanent 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 1�PIo copy of this record has been provided to the well owner.
Ift his is a repair,fill out known well construction information and explain.the nature of the
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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple hyection 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'and2@100� construction to the following:2 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use^+'• 1617 Mail Service Center,Raleigh,NC 276994617
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 276994636
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
granular hypochelrite well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed. �
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013