GW1--05235_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kennedy 14.WATER ZONES
Billy7 FROM TO DESCRIPTION
Well Contractor Name us-ft. /J n ft. 'a j-j, "
2834-A I ft. Imo"" ft. Jl"
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a cable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft• till ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TURING(geothermal closed-loop)
3�s3 FROM TO DIAMETER TIHCKNESS MATERIAL
2.Well Construction Permit#: 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 TRIMNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Muni ipal/Public
❑Geothermal(Heating/Cooling Supply) -e;sidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 16.
FROMGROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft' Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft. /D
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology 0 Subsidence Control —
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling
Return) ❑Other(explain under#21 Remarks) 0 it
._4--". Aft
4.Date Well(s)Completed: O -a`ii�Vell ID# _S ft. 30 ft. 7 „//`r•t cycle-
30,
Sa Well Location: ft. pi?ft. /C7/��C�a1,OCis!k[L
J ft. J ft. , . !
te� /0/e h ft. ft. _.- �...
Facility/Owner Name Facility ID#(if applicable) CEP ) 3 2 O 2 4
S.
}- � ft, ft. SEP
4 J 67� /a /Lee/ ft.
Physical Address.(ns..md Zip
21.REMARKS L
JL 6wf 36,3
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W
Signature ertifed Well Contractor Date
6.Is(are)the well(s): rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yea or Bl 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:
You may use the back of this page to provide additional well site details or well
8.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
9.Total well depth below land surface: l 13 (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@20D'and
2@1100') construction to the following:
10.Static water level below top of casing: as (g,) Division of Water Resources,Information Processing Unit,
If water level is above casinguse'•+,• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 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:
(ie.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) QC7 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochiorite /DoZ well construction to the county health department of the county where
1 3b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013