GW1--01014_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ,
1.Well Contractor Information: '
Bill Kennedy 14.WATER ZONES - ' '''; ..
Y Y FROM TO DESCRIPTION
Well Contractor Name Jseft- /39.ft. /� n�
2834-A ft. ft. �p .
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased.wells)OR LINER(if ap [feeble) '
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. el ft• 6.25 ; SDR-21 PVC '
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
,,/lYf ��„S `/ FROM _ TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (r i.., VZ ft. ft. 1 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.
❑Agricultural ❑Municipal/Public i'
❑Geothermal(Heating/Cooling Supply) sid eential Water Supply(single) ft' ft. in.
18.GROUT
❑Industnal/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: - - -
ft. ft.
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if"applcablej ' -
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) .- - .
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. S- ft. eiet-
_ �
4.Date Well(s)Completed: /3' 5
t / Well ID# �ft.
L 30 ft.
L 4 0 z `�""y
5a.Well Location: 30 ft.
L 70 R• d e w e
�� j 7Q ft. ��J R f� � .
, �tt r a/tux 6, /'t!J/Gt4(t1tJ✓t ft. ft. E.a.''.. +� `V t Li
V � `.L'LA L.�a
Facility/Owner Name Facility ID#(if applicable)
.. S jr ) ft. ft. �
73 7 /°lLLk e.49,,e✓ 6°14le i ft. ft. FEB 0 2024
-- , Physical Addres City,and Zip
21.REMARKS i'',- trii.T;'•?;i.-i ►rr9tW4
r. .r e'UFA
Act olloA 7G337Ds333o
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 1 /-3 - ay
Signature o ertified Well Contractor Date
6.Is(are)the well(s): L3Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
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 IT o copy of this record has been provided io 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
8.Number of wells constructed: i 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: igir-
(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:
I
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Services Center,nter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Inlection 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: 1
(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
d i
13a.Yield(gpm) cp 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: �0
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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