GW1--06304_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1 '
This form can be used for single or multiple wells '
1.Well Contractor Information:
Bill !Kennedy ..14.WATER ZONES . :r€,':::_
Y y FROM TO DESCRIPTION
Well Contractor Name haggft. �2��'em
2834-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 119 ft. 6.25 , in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f . —0 000/6 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
ft ft in.
DAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) dential 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)- 1.
FROM TO MATERIAL EMPLACEMENT METHOD •
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ' ❑Stormwater Drainage
ft. ft.
[Experimental Technology ❑Subsidence Control 20.I)RILLINGi OG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,strain size,ete.)
❑Geothermal(Heating/Cooling Return)/ ❑Other(explain under#21 Remarks) 0 ft• 6 ft /viG K - „ a. "-vac.
4.Date Well(s)Completed: ?"-�(- ell ID# 3 it t 0 ft 8 nve jM te,, �e "-vac.
5a.Well Loc on: . -y((� ft 3(as''ft / �•`d'I��G
/�,,/t [ ! ft ft.
i ,, .re e al W 7//il a e17 J m I`1'i ft. ft F;t'-., y v p� .
rh
Facility/Owner Name Facility ID# f applicable) g ft •.� `-'P jy."@ at'
`fi-3 4orl Gra.-�v /lr ft. ft. SEP r 6 2023
Physical Address, ity,and Zip -
_
I a d,L 7 as 6, $7q/ Into 4;t ..r g I r
County Parcel Identification No.(PIN) " d u
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) �/f
N W JrNi/ / °?l-o23
Signature of Gfied Well Contractor Date
6.Is(are)the well(s): eC7F rmanent or ❑Temporary By signing this form,I hereby certj that the well(s)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 o 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: .
8.Number of wells constructed: / You may use the back of this page to provide additional well site details or well
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: ' .2✓[ (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 cJ200'and 2Q100') construction to the following:
10.Static water level below top of casing: a'' (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 Iniection 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) c)--- Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: ��el 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 i Resources Revised August 2013
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