GW1--04737_Well Construction - GW1_20230724

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
11 I
Bill Kennedy14.WATER ZONES.:
Y FROM TO DESCRIPTION
Well Contractor Name 0� ft. /o ft. a_
QyR/ r7G/�.f J I` �*4-
2834-A 3g0 tt. ;� t' / /e,ill
NC Well Contractor Certification Number 15.OUTER CASING(for inultiA4A sed wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling o it' 7 ft• 6.25 In. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3,j S,� ft. ft in.
List all applicable well permits(Le.County,Slat,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 ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) GYIreesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
I:Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACE➢fENTDtETHOD
tt, ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) „
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d ft• Ls-- It
4.Date Well(s)Completed: 67_6 ell ID# ft. ft. �Y7 ^��
P /j �y�,p"
Sa.Well Location: o20 ft t/D ft 6 c�' " `r t0��
-•• n8't f y //0 ft. [ d�fte � _ !,
ft.
ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. "� * { '^�t
-T-6119 p;&f kt ft. ft. (�
Physical Address,City;and Zip • 21.REMARKS ' nil. .4 2023
AO/P aooao/6, UM
County - Parcel Identification No.(PIN) t yrf eaLtst t •.--_ t�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) . /
N W Vai / (A 6 3
Signature o ied Well Contractor Date
6.Is(are)the well(s): 2<manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
Cl '
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 i;1Vo 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 thisfonn. 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: g (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@100') construction to the following:
10.Static water level below top of casing: ‘10 (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 m ! �/ Air 24c.For Water Supply&Injection Wells:
(gpm) /J� Method of test: Also submit one copy of this form within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
)
13b.Disinfection type: Amount: 1670 constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013