GW1--04750_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
BillyKennedy14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ,sO ft. S' ft 1/&of
2834-A /SD rt. is-5-ft- a }'
ys. 4,0 Alt
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casetl'w )OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ® ft 3 7 ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop), "
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County, tate,Variance,Injection,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water�Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I��Agncultural ❑Municipal/Public ft. ft. In.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) „
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEAiENTDIETHOD
ft ft.
DAquifer Test ❑Stormwater Drainage •
ft. ft.
DExperimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
•
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. a ft. /��'P t
4.Date Well(s)Completed: tp-a&43 Well ID# pZ ft. 30 ft. °� _/C
5a.Well Location: 30 ft.. rl`eft ✓3e#o k_ yr
/ ''�� ft. OtV ft �J
k.1(4Is•P_ alert .bhrnSOPi J 7 ft ftRil: r+► a. e
Facility/Owner Name Facility ID#(if applicable) (P 0 ��
ft. ft.
740 6�r Roc-k Ad ft. ft. JUL 2 4 20Z3
Physical Address,City and Zip .
D / 21.REMARKS. t t .
Aaike / k 697?3qI33 1 I tn�r ";►�-',;:.::_�::r Jc.
County n 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)
33.75'3'("78' N iC0foal' o't3/ w Adizt if<.>�- ---c. �o-alo- a3
� Signature erti ed Well Contractor Date
6.Is(are)the well(s): IaPe -anent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
wills ISA 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 1214o copy of this record has been provided to the well owner.
If this 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with t e same construction,you can
submit one form. ++�� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: t2.COQ (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@100) construction to the following:
10.Static water level below top of casing: 30 (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: G.26 (in.) 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: ry 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) 3 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:
B‹--- -constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013