GW1--05923_Well Construction - GW1_20230918

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WELL CONSTRUCTION RECORD For Internal Use ONLY: ,
This form can be used for single or multiple wells 1 I
1.Well Contractor Information:
Billy Kennedy �FRoM TO ZONES DESCRIPTION
Well Contractor Name • //Sft. //7 ft. i
pr%�
2834-A l fo3 ft. /6 ft. 3; s id{M
NC Well Contractor Certification Number -t15.OUTER CASING(for multi- S<.wells)OR LINER(if ap.licable), - •
FROM TO DIAMETER; THICKNESS MATERIAL
Kennedy Well Drilling 6 ft a,,3 ft• 6.25 I iin• SDR-21 PVC
Company Name .,16.INNER CASING OR TUBING(geothermal closed-loop)
1 /y FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: oZ�ot� O(/��O 90 ft. ft 1 in.
List all applicable well permits(.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 ❑Munigipal/Public ft ft in:
0 Geothermal(Heating/Cooling Supply) Eitesidential Water Supply(single) ft. ft. In.
18.GROUT
0 Industrial/Commercial ❑Residential Water Supply(shared) FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery it ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
Experimental Technology 0Subsidence Control ft it
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❑
20.DRILLING LOG(attach additional sheets if necessary) !."..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ON(color,hardness,soi0rock type,grain size,etc.)
❑Geothemral(Heating/Cooling Return) DOther(explain under#21 Remarks) ® ft. ft. [
!� c�uyn
4.Date Well(s)Completed: $' Well ID# C� ft / ...
ft. �� I1Pie._Sa.Well Location: /c it ft_ A-"' ate``, ..
/ ' ft. ft. ( %`, .'i r",..7.,A
S7 ,ght.av? 7v/QO' ft. ft. •
Z _'" i 1 5""
Facility/�OerNampme J /� Facility ID#(if applicable) ft. SL N 1 2023
7119 Ao.cs 1�t2// t.S �/ ft. ft. l 8 LJ
Physical Address City,and Zip _ 21.REMARKS inf^✓j�� 7 Pr p ' '"'7 fir!
/-t2N Id lid A76' 7a.7S7 60 ,
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 8 di/ f1/o - , -�'-aJ
Signature f ertified Well Contractor Date
6.Is(are)the well(s):. Permanent or ❑Temporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
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with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Pic i 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:
(7) You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: a,.? / 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 fonn. (� SUBMITTAL INSTUCTIONS !
9.Total well depth below land surface: /p S (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 2Q100) construction to the following: I '
10.Static water level below top of casing: TO (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: 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: rotary 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 Ce!ter,Raleigh,NC 27699-1636
13a.Yield(gpm) V' 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: /00?
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WatertResources Revised August 2013
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