GW1--06300_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD For Internal Use ONLY: ( '
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennedy ''14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 1/ % ft. ive ft. O�t14
2834-A �A ft. ft. J ✓f '
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NC Well Contractor Certification Number "15.OUTER CASING(for multi-cased wells)OR LINER(if ap &able)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Kennedy Well Drilling I) ft. /eft. 6.25 I SDR-21 PVC
Company Name 16:INNER CASING OR TUBING(geothermal closed-loop) ,'
[y FROM TO DIAMETER THICKNESS ' MATERIAL
'jS !..2.Well Construction Permit#: 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 ❑Municipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) 2<idential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remetiiation -19.SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E1IIPLACEDiENTDiETHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
Y
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,solltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)t ❑Other(explain under#21 Remarks) 0 ft. t9 ft. C ft��;
4.Date Well(s)Completed: k-1 7 Well ID# -_ - ft. (�0 it _ ""*�r—
Sa.Well Location: Lf 7 ft. 70 ft" YE''lag) 0/,1 P r
�2�!) 0 Ad-cc 0 ft.ft /a�-ft. ,d it Sa� dir f
Facility/Owner Name Facility ID#(if applicable) r+� I / �til�
Ya"/� 6 ' ) n ft. ft.
Physical Address,City,and Zip` ft. ft. -` _d w t)� {i !-
21.REMARKS .-
/Aa//'U _ .s-70q SEP 2 6 2023
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i CAN Cu COG
(if well field,one lat/long is sufficient) �i r 7 ^'
N W natu� d Date
^ ( / 0L
i,y' Signature of ertifie Well Contractor Dat
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify 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 faiVO 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
S.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 sane construction,you can
submit one font. pp SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: /t'5 (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'andtt2@100) construction to the following:T 10.Static water level below top of casing: ° (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: 6.2 5 (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
30 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Alssolubmit one copy of this forme within 30 days of completion of
granular hypocholrite 13b.Disinfection type: Amount fade, well construction to the county health department of the county where
-constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water ef Resources Revised August 2013