GW1--03850_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Tltis form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy/ 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name t10 ft. ft.
2834-A ft. a rc.
NC Well Contractor CertifiicationNumber IS.'OUTERCASING(for.mul' sedwells`OR LINER(if Ilcable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft. 3 il" 6.25 in SDR-21 I PVC
Company Name 16.ENNER.CASING OR TUBING(eothermal cIosed4ob' . .
'J/� 70 FROM TO ft DIAMETER�-
THICKNESS MATERIAL
2.Well Construction Permit#: 7 tt•
List all applicable well permits ri.e_Counh;State,Variance,li jection,etc.) ft. ft. in.
3.Well Use(check well use): 17-SCREEN.
Water Supply Well: FROM To DIAMETER SLOTSIZE THICKNESS MATERLII.
❑Agricultural ❑M -'pal/Public ft. fL In.
❑Geothermal(Heating/Cooling Supply) C�itesidential Water Supply(single) ft. ft. in.
❑Industria/Commercial ❑Residential Water Supply(shared) 15:GROUT
FROM TO MATERIAL EBIPLACEMENT METHOD&AMOUNT
❑h-ri ation 0 ft, 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 49:SANDIGRAVELPACK if a licabl'e _ ..
El Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL I E11iPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control
.20i DRILLING LOG'att4ch'Additibuid sheits;if recess
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIMOx color,hardness,soil/rack type,groin size,err
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) 10
ft. ft•
ft. ft.
4.Date Wells)Completeds-�> - Q3 Well ID# g, ft.
59./Well fL�occationn: / � 1_�,
LrWta" xS 1 t'6ICU /(�"""e' JV6'!�!-s tt. it
Facility/Owner Name Facility 1p#(if applicable) h ft.
M .
LJ
ft. ft.
Physical Address,City,and Zip 1 I W 7 a
2i<REnIARxs:..: .
-.Awny, �r� to a .rsti n �r:Y 3s21�A Ua
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
N W t
� Signatur0' Certified Well Contractor Date
6.Is(are)the well(s): BPermanent or ❑Temporary By signing this foray,1 hereby certify that the well(s)was(were)constructed in accordance
! with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 09. copy of this record has been provided to the well owner.
If this is a repair,fill out bmown well construction information and explain the nature of the
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: f construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,),on can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 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@I001 construction to the following:
10.Static water level below top of casing: l30 (ft.) Division of Water Resources,Information Processing Unit,
V'umter level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) q Method of test• Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholdte /�� well construction to the county,health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013