GW1--07732_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy Id.WATER ZONES t":+ . •., ,
FROM TO DESCRIPTION
Well ContractorName t. Alt ft 4/
2834-A • S11 rid 11
NC Well Contractor Certification Number ;15.:OUTE1tCASING(for ntnitl ii*d wells)OR LINER(If 10 It able)".
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling D ft- 6.0. ft 6.25 in. SDR-21 PVC
Company Name :1"fi1NNER�'CASING;OR•TUBING eothetrnal closed�loo ' '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:4 �I" ?00 3 id ft. ft. In.
List all applicable well permits(i.e.County.State,Variance,Injection,etc.)
ft. ft. ln.
3.Well Use(check well use): 17i[SCREEN"'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Muriel al/Public
❑Geothermal(Heating/Cooling Supply) Supply(single)
ft tt In.
(Heatin Coolin Su 1 esidential Water S 1
;GROUT.
❑Industrial/
Commercial ❑Residential Water Supply(shared) - " - '�•-°
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft 20+ n- Bentonite Hydrate chips in place
Non-Water Supply Well: Y P
ft. ft.
-_. ❑Monitoring ❑Recovery
Injection Well: ft.' ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.+SAND/GRAVEL:PACK(tf applicable) 'a . _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO -MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology OSubsidence Control
-20 DRILLING LOG:(attach additional sheets'if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DENS rCRrfIQN(color hardness,soil/rock type,grain size,etc.) s
❑Geothermal(Heating/Cooling Return)r� ❑Other(explain under#21 Remarks) it• -Or'
/`1( c..._ �/
4.Date Well(s)Completed:/ fX)' t3 Well ID# licit.f fi �'` fr� �f©f�/'( `/"�" /
a.sco-- ft. �!r a r ��21iO �r�1(�
5a.Well Location: 2 `art.
.: 0c Lynch /ft.
1 ft • `e
Facilittyy/O�wneerrName Facility ID#(if applicable) ft
�(i /tO tei f :' w .4. r c. S"'•I
ft, ft.
.,.
Physical Address,City,and Zip Q r r
21.REt1IARKS , ._ _ 2QZ;i . ,
Arktly9M-e 77.5"�•.-G90-3?•-73,22
County / Parcel Identification No.(PIN) E z
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one let/long is sufficient)
N W lv.w03
Signature ettified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary 1
By signing this form,I herebyxertn,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1;ifilir 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 I.
submit one form. ��"" SUBMTITAL INSTUCTIONS
9.Total well depth below land surface: /(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 2(41100) construction to the following:
10.Static water level below top of casing: '..TS (it) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mail Service,Center,Raleigh,NC 27699-1617
I ,
11.Borehole diameter: 6.25 ('m-) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
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 ,
(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) i( Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypachofite well construction to the coup form
department of the countywhere
13b.Disinfection type: Amount: .r constructed. ty
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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