GW1--04797_Well Construction - GW1_20230721

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 ? ft. 2 ft. I �"
2834-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If op"ilcable) '
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling (J ft. i/ ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geotbefrnal closed-loon)
� j j FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 01 /-7 5)4 If, ft. ft. in.
List all applicable well permits(i.e.Coun%State,Variance,Injection,etc.) ft. ft. In
3.Well Use(check well use): 17.SCREEN:.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) rtRestdential Water Supply(single) ft. ft. In.
❑Indus trial/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: ft ft.
❑Monitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge 0 Groundwater Remediation -19:SAND/GRAVEL PACK(if applicable) . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MErHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control _20.DRILLING LOG(attach additional sheets ifnecessary)-
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES TION(color,hardness,sall/rack type,grain stze,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b ft• a ft. i r i--
4.Date Well(s)Completed:6-i7 Well ID#
a ft- S71.5`�'f' / Jte .vc_
ft. ft.
5a.Well Location: _
j� Jr:, t. ft. A E R vE`
rJef.1'✓��1./ �1C',• C�t'.�-�S Q�.'i .0• ft. ft. ��L'���i �i If�')
Facility/Os iterName Facility ID#(if applicable)
ft. ft.L JUL 2 1 2023
/'70 -.1rt.do,. y�.�.•✓ , ft. ft.
Physical Address,City,and Zip
G � �»� 21-REMARKS . Nl#Or1IiN Oft Pft,Ct149417 j Utflai
75`Isi/ D1AtO1300
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 464 /4.."1-1am t'-/7 -ai
Signanne of Certified Well Contractor Date
6.Is(are)the well(s): �manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 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 ©i'co 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 fonn. 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 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: J e s- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dperent(example-3(a 200'and 2Q100) construction to the following:
10.Static water level below top of casing: 60 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
rotary24a 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) / Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite �/ well construction to the county health department of the county where
136.Disinfection type: Amount: /(S ri A
constructed.
•
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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