GW1--05917_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
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1.Well Contractor Information:
14.WATER ZONES' T '..
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ,5Qft. jci ft. 3;"
2834-A a7 ft: /DS51L t
NC Well Contractor Certification Number IS.OUTER CASING(for,muttt ed ivells).OR LINER(If ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling p
ft 6, i it. 6.25: is SDR-21 PVC
Company Name 1 R.CASING OR-TUBING(geothermal clased.loop)
L,L / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4` ,S* ir �9 ft. ft. in.
List all applicable well porn:its(i.e.County,State,Variance, jection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.. in.
❑Agricultural ❑M ipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft to.
❑lndustrial/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: Y P
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
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❑Aquifer Recharge ❑Groundwater Remediation D.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it. it.
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control '
20.DRILLING LOG(attach additional sheets if necessary) • _
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION ccolor,hardness,sollrocktype,grain du,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © ft. Ja ft. R,/,, ,,1
4.Date Well(s)Completed:o' RV Well # CI R. /© ft.
Afel6teseet cW1�
Sa.Well Location: [0 ft. CO ft. t edi -
Facility/Owner Name Facility IDit(if applicable) • ft ft.
p!�(/V`ifebb$�'.l a Gvi chili'e'! R ft. ft. : \ '/b.�0,_r iiV?�,i
Physical Address,City,and Zip p _
21:REMARKS :. S E. 3 2023.
County Parcel n cation No.(PIN) InfoTtnle;'^rl Pn'1,: t11.9 Lira
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: G�•ti.�'
(if well field,one lat/long is sufficient) 22.Certification: i
. N w AlJ _.,,,..,,,:jek f(:-- a?-013
Signature ddertified Well Contractor Date
• 6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby cer tif that the well(s)was(were)constructed in accordance
�� with I5A 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 LBIVo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it formation 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 sante construction.you can
submit one form. SUBMITTAL INSTUCTIONS,
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2Q100') construction to the following:
10.Static water level below top of casing; WO (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: 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) .....6." Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fora within 30 days of completion of
136.Disinfection type: granular hypocholrite Amount: r�j�t well construction to the county!health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013 •