GW1--05200_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FRO EWATER TOSS DESCRIPTION
Well Contractor Name j V ft. alp ft Yas,,ya
2834-A ixdyft. (y ft.
gee Ph
NC Well Contractor Certification Number 15.OUTER CASING(for multi-e5sed,wells)OR LINER(if ap licable)
FROM TO DIAMETER _ THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. a7 ft• 6.25 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
nn pp��++��� /��v� )�/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: cao,)3 -OO/C�/s3-y 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 OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) e-idential Water Supply(single) ft ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft' Bentonite Hydrate chips in place
Non-Water Supply Well:
ft ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft, 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(colop hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling
g�Return) 0 Other(explain under#21 Remarks) 0 ft. 11 ft 6.v4" . ' ef
4.Date Well(s)Completed: U -/- .23Well ID# ft. S J ft. 4 iv i51 It.e-
Sa.Well Location: /J ft. 'it. , ed/oc-L ' '''`,
a.Well
ft. ft. '� Cd F '•_r E k its a F 9 8
/71ii5S-e V ft. ft. �" L !�
Facility/Own Name
iJ Facility ID#(if applicable) ft ft AUG f i' j Z f'Z 3
r LJ 'Flat- t�'r a-e Lt ft. ft. l-1 U 2 s 1J
Physical AddrAn n/idt
e City,and Zip Ir+-c.^rrrz',+2.1 Pr. ^!.".,.�D tIC
21.REMARKS": �ti�)%,;,c✓,fit+'
ari
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) G
N W ,/ k� . C3 - / -.23
� Signature ertified Well Contractor Date
6.Is(are)the well(s): Ed manent or ❑Temporary By signing this form,I hereby cert fy 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 ETKO 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 fonn. 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-u (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: /dO (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 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: 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
tAir 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) a Method of test: Also submit one copy of this fonn within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013