GW1--06920_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD For Intemai Use ONLY: -
This form can be used for single or multiple wells •
1.Well Contractor Information:
Bill Kennedy 14.`WATERZONES i
.1 y FROM TO DESCRIPTION
Well Contractor Name l,ft e .oft. T.0
2834-A ai0 ft aifa.ft. is---.. /t l
NC Well Contractor Certification Number ;15b'OUTERCASING(for mnitl=ca' ells).ORLINER`(tfap"-licable):_-' _:
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 73 ft 6.25 I' in• SDR-21 PVC
Company Name 16:INNER CASING;OR.TUBING(peotherurol closed-loop),
FROM
2.Well Construction Permit#: ®t�. � ft. TO
ft. DIAMETER THICKNESS MATERIAL
in
List all applicable well permits(i.e.County,State, ar �� �rG Aiance,Infection,etc.)
ft. ft, is
3.Well Use(check well use):
Water apply Well: FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
gncultural ❑Municipal/Public ft. IL ill.
❑Geothermal((Heating/Cooling Supply) ❑Residential Water Supply(single) B ft. in.
( ) 1&(GROUT
❑In usttia Commercial ❑Residential Water Supplyshared - -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0
Non-Water Supply Well: ft 20+ ft Bentonite Hydrate chips in place
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft. •
❑Aquifer Recharge ❑Groundwater Remediation •:19:-SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology 0 Subsidence Control ,:2 DRILLING LOG.'(attach:addittona s.eets'if necessary)::<
❑Geothermal(Closed Loop) ❑Tracer FROM TO N(color,lo hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) ® ft Er ft. DESCt*//O[
4.Date Well(s)Completed: /0`a`°Z�Well ID#
e;; :: tL : Acoa ,f 3
Sa.Well Location: . �" ��
ft. ft
Ye ffetAli 4%0Gke y ft. tt- . -l: " ''
Facility/OwnerN a Facility11 #(if liable a `'
ft. IL I
l,avr For i'. 6fe•ek. 4,1 a ft. rt. NOV 1 5 COZit
Physical Ad ,City,and Zip •
-21 REMARKS,
J .
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 iGr,•yru ' ile 3-a9
� Signature' ified Well Contractor Date
6.Is(are)the well(s): LSrermanent or OTemporary I.
By signing this form,I hereby certify that the wells)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 °Mr copy of this record has been provided to the well maser.
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: if 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 forni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: W-3 (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@I00) construction to the following:
10.Static water level below top of casing: h/S— (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
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) e�® Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fond,within 30 days of completion of
granular hypocholrite well construction to the countyhealth'department of the countywhere
13b.Disinfection type: Amount: f a t's, constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013