GW1--06280_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy .14:WATER ZONES , :l;
Y FROM TO DESCRIPTION
Well Contractor Name 65-1(ft. Cre it
yl l
2834-A 17811 Jgc rt. (,g¢ rr,
NC Well Contractor Certification Number 15.OUTER CASING(for multi- 16 wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling • 0 ft. SO ft• 6.25 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -
G FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 O 4j o 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
DAgricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Cleglential 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 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEt1fENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)u OOther(explain under#21 Remarks) 0 ft. 0 ft.
4.Date Well(s)Completed: 7'Ot0`c ..3�ell ID# ft L/© ft C f
P � 7
5a.Well Location: /1O ft. q� ft. / e fle
-r �J/� sit/
y ft (loon. af ed) c K-
VfA!-ob 6" .A•l>t'v!. ft. ft.
Facility/Owner Name / F ility lD#(if applicable) g ft. -`i ",,r' �~--
/l7� /,M 6; /1rr`� gel ft. ft. y 6 -✓11a.; �t 1....?
6 .2e23
Physical Address,City,and Zip 7 S E i , J
C/"E -�N'� VO l(/o 21:REMARKS.;. r ,,., ..
in`p 4;^.71?r rZ•Wol$sl iUI
County Parcel Identification No.(PIN) DWCii;?,CQ
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
N W � J+ 7`ao-a13
Signs o Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance .
with 15A 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 124 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: 1 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: ale0 (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: 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
(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) g 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 //��oZ well construction to the county'health department of the county where
136.Disinfection type: Amount: )0 constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013