GW1--04736_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennedy l4 WATER`ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name If0 ft.
i/01 ft r 5,i41
2834-A ft. ft.
NC Well Contractor Certification Number 45.OUTER CASING(for multi-cased wells)OR-LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 fa cifol_ft. 6.25 in. SDR-21 PVC
Company Name '16 INNER CASING_OR TUBING'((eothermal closed=loop)
� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit At: 4/ 24 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft
3.Well Use(check well use): 917:'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
OGeothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft In.
es
❑Industrial/Commercial ❑Residential Water Supply(shared) •'1gJ GROUT..
FROM TO AIATEAfAL EMPLACEMENT METHOD ti AMOUNT
❑Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Infection Well: ft. ft.
❑Aquifer Recharge. ❑GroundwaterRemediation 19'SAND/GRAVEL PACK(U applicable) •-•
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FMPLACElfED1TDILrrHOD
ft. f4
❑Aquifer Test ❑Stormwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control
:20 DRILLING LOG(attach additional sheets if necessary); ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES�RtP1TON(color,hardness,soil/roek type,gain sloe,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f• .''-- ft ��
a 7 D# /�V44
ft ft Ce
CIC
4.Date Well(s)Completed: 7 f, Well I
Sa.Well Location: ,30 ft / ft.
d/
F II 4 -��. ft.
L.v eifiAe ! / ft. ft.
Facili`i//Owner Name Facility ID#(if applicable) �%� } ,
ft. ft. t P t:.E-iVELT
5-go 6004/o, ,�f'. ft. ' ft. I
physica\Aastas,City,andZap G nnn ,
Ade/e. /9, 40e 2 9a
County Parcel Identification No.(P1N) f )rT+'tN�^i """"'y')UrrAPKVCOG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/long is sufficient)
N W /CeA-4-")t"e-44--- 7-6 ,13
/� Signature ' edified Well Contractor Date
6.Is(are)the well(s): C�tPermanent or OTemporary By signing this form,I hereby certiify that the wrll(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 ❑No copy of this record has been provided to the well owner.
Ifthis 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 fonn. 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 ON P with the same construction,you can
submit one form. j SUBMITTAL INSTUCTIONS
!9.Total well depth below land surface: t2S (ft) 24a. For All Well: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: JO (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use..+" 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
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i'7 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
t. a��
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: granular hypocholrite Amount: ��� well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Deparhnent of Environment and Natural Resources—Division of Water Resources Revised August 2013