GW1--03872_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name sSr" ft. 60 ft. st
•••"4
^
2834 A �$D ft. /ga It. /
NC Well Contracwr Certification Number 15.OUTER CASING(for multi wells)OR LINER(If applicable/
FROM TO DiAME(17t THI(KNESS MATERIAL
Kennedy Well Drilling D ft. c�(/j ft- 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal elosed400p)
�D 7� ,/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f!� 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
❑Agricultural ❑Mu��nicipal/Public ft. ft in.
❑Geothemal(Heating/Cooling Supply) rdResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 111.GROUT
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NonWat r Supply Well: 0 f`' 20+ n• Bentonite Hydrate chips in place
ft. ft.
OMonitoring ❑Recovery
Injection Weil: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 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 D WrION(color,hardness.soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• a, ft. u•rf
4.Date Well(s)Completed: Wdl II)# a %f'� "
ft. ao3 ft. d /o
5a.Well Location: ft. ft. ..i;...\, r J E j
LI:peril Herne ZieI li''S ft. ft. II!N A 2fl2d
Facility/OwnerXXame Facility ID#(if applicable)
(,� J ft. ft.
/G�Dj //af-/.. /�/I ft. ft. irgerw04et'a, P•e.-eAsenit Unit
Physical Address,City,and Zip ►CS 304:
21.REMARKS
AIVerP- DG /1/V4
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)
yN W no J "oft
Signs .11 Certified Well Contractor Date
6.Is(are)the well(a): irmanent or OTemporary By signing this form,I hereby certify 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 War 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: e103 (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 d 200'and 2@100') construction to the following:
10.Static water level below top of casing: OfJ'�
, (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"i" 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
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(re.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) /(5 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochbrite 13b.Disinfection type: Amount: la0=
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 Resources Revised August 2013