GW1--05273_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATERZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name yCo ft. tX• ft. a iyleit
2834-A �f? ft —n .l17,�''�
NC Well Contractor Certification Number 1S.OUTER CASING(for niulti ells)ORLINER(if appllcable),,r - .._
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 3,3 ft. 6.25 in' SDR-21 PVC
Company Name ;16:INNERCASING OR.TUBING'(geotherni l dosed-loop): -::
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 41/(5?/>�3�l 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑,Mu-nicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) .ElResidential Water Supply(single) ft. ft. in.
❑lndustrial/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. ft.
❑Aquifer Recharge ❑Groundwater Remediation .,19.SAPID/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ;20 DRILLING LOG(attach additional sheets If necessary) .
❑Geothermal(Closed Loop) OTracer FROM TO DES ON(color,hardness,so0/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ft. /ge f-
4.Date Well(s)Completed: T ®iA.� Well ID# " Qv f t A"riG/L •
ADS ' A
5a.Well Locatlo .20 ft. e'l•,pr.k
f),y /) ,4I/r/v' kr". ft. ft.
Facility/Owner Name Facility ID#(if applicable)
�•�- /P /� ft ft
J a 7 aia btet1U !r ft. it. ( '" Y a e)
Physical Address,City,and Zip , `" �f "
11::REMu(RKS
Aotfe- eooeo 90 AUG 1 2023
County Parcel Identification No.(PIN)
tr,:..;.'.-`ti.,.i Pr.-- -'.r•,-- I Iry
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: D l73(
(if well field,one lat/long is sufficient) 2
Signatureo.a1&LifiedWell�or t;J Date
6.Is(are)the well(s): Wermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 ❑No copy of this record has been provided to the well owner.
If this is a repair,Jill 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. rr�� 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'and 2Qa 100) construction to the following:
10.Static water level below top of casing: as" (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" • 1617 Mall 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
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) / a, 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
13b.Disinfection type: Amount: `e2® constructed
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013____>.