GW1--02331_Well Construction - GW1_20240410

,
For Internal Use ONLY:
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1.Well Contractor Information: :
Bill Kennedy 14.WATER ZONES . - >> _
Y y FROM TO
TO DESCRIPTION
Well Contractor Name ,X ft. /r)I ft / iN1
2834-A ! ft. /DU ft. lo`S�i i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR`-LINER Of licablc) _
FROM TO DIAMETER., THICKNESS MATERIAL
Kennedy Well Drilling D ft. 60 ft 6.25 F. ►n' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Iti� � FROM TO DIAMETER THICKNESS MATERIAL[
2.Well Construction Permit#: it ft. in
List all applicable well permits(Le County,State,Variance,bjection,etc.)
ft ft • in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muunicipa]/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) la'Residential Water Supply(single) ft. ft in.,
18.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) `L
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring DRecovery ft. ft.
Injection Well: ft. ft. '
❑Aquifer Recharge ❑Groundwater Remediation ,,19.SAND/GRAVEL PACK(if applicable) . ., ;+;'c'' ?
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage -
ft ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)' "-.. 1`'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock
type,grain size,etc.) ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) w
/7 ft �/ ft. �� C�� Q^� U ft 7 ft. s J A f..
/ /
4.Date Wells)Completed: 3 a�'of •Well ID# `� O
Its t. X k
5a.Well Location: �t7G T F
t 122 t. /93 ft' ��%,cl� I:,: c. +i�,i'`1 f r....j,.._
�(:� /'�11�fP S� ft. ft. APR
Facility/Owner Name Facility ID#(if applicable) 1 6{ .2 024
ft [t. V
/$c t' ,o/ ,Sp r•' S Id ft. ft. ,
tr,;4 41^71 Pr.7,n&v:o.-.4rxt lln:is
Physical Address,City,and Zip
21.REMARKS .;... _ • ;' t. Jr'rtfrtC,E:SRrx .':•:_..:
Ado/e- BOOOOO6e
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 3-a/-0 ‘-/
���._// Signature edified Well Contractor Date
6.Is(are)the well(s): C1f'ermament or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 12ffir 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: 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 1
9.Total well depth below land surface: /V3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i different 3 00'and 2 100 construction to the following:P .f (example- @2 � � g: 1
10.Static water level below top of casing: 3-C- (ft-) Division of Water Resources,Information Processing Unit,
If water 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
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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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: de
®� well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013