GW1--05143_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Internal Use ONLY: ,
This form can be used for single or multiple wells
1.Well Contractor Information: t
BillyKennedy14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name e"(s'ft. (3 ft. /I Qe
2834-A L ft. ( ft �/
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if applicable)
MOM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 4 ft. (3 ft. 6.25 In. , -igge &J- .. f
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: '' CIO 7 77 ft ft. in.
List all applicable well permits(i.e Counry,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
ft. ft In.
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) .lResidential Water Supply(single) ft ft. In.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18..GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. it.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control _20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCR N(colt'*hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft es- ft ,o ,,, k
�+� ft. Jri- ft. j6 '� [f'17
4.Date Well(s)Completed: 7-01 0 3Well m# •7 J /� /��
5a.Well Location: J t / �J f-
n ,,� I ft, it.
Facility/Owner Name Facility ID#(if applicable) ft. fr. ‘ L E @ 1...f�;3 `i... /,. ft ft 1w 1 8 2023
Physical Address,City,and Zip
CAs 's-t & i 77 7 i,ri-Utmra►ttry::�n r�rvcumirq LingDV '',
County Parcel Identification No.(PIN) '-
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W Z-eel
ju�/Y�(t 7 p
Signature oed Well Contractor Date
6.Is(are)the well(s): rirermanent or ❑Temporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
_� with 15A NCAC 02C.0I00 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lilt( 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 421 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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ii/46e. (it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2 0'and 2©100) construction to the following:
10.Static water level below top of casing: 1715 (ft.) Division of Water Resources,Information Processing Unit,
Iwaler 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
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) 1 O Method of test: Air 24c.For Water Supply Sc Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrtte Amount: ' 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