GW1--07740_Well Construction - GW1_20231204

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: •
Billy Kennedy FROM:FROM
TO DESCRIPTION
Well Contractor Name /g)ft. /G7 ft. ) 1�a I `
2834-A ft O ft. ' �c✓t�dt
NC Well Contractor Certification Number
.15.&OUTERCASING.(fo muhl-casedwells).ORLINERltfan tieable) ` :.
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft oty rt 6.25 ' hi' SDR-21 PVC
Company Name ',16:INNER:CASING:OR TUBING(geothermal losed loop)'
P� ' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4dr ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft ; in.
3.Well Use(check well use): 17P SCREEN . ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ..al/Public ft ft. in.!
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. B In.
❑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.
❑Monitoring ❑Recovery
Injection Well: ft. ft. -
❑AquiferRecharge ❑GroundwaterRemediation :19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
i
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20•DRILLING LOG(attach addidonalsheefs if ikessarv) , -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESS 'TON(color,hardness.soil/rock type,grain she,eta)
❑Geothermal(Heating/CoolingRetumG) ^❑Other(explain under#21 Remarks) L9 ft /05--ft• i v'
4.Date Well(s)Completed:/0- O C ell ID# ft B dco is1 r e-
Sa Well Location: /0 it
3( ft. �,A iC
ft. c� R. !ll���[(�� i
Ar lion Cee//.less ft. ft. E -Y;'. '-- '. '. _ .
Facility/Owner same Facility ID#(if livable) s`= r: '%f ?'
ft. ft.
�y,� /_ 2023
ft. ft I,
Physical Address,City,and Zip ,21 1tErimARKs , 1:IS.3 t, if`0R 7 ,t= , r
inalr ee 00110 ia8'6' r,,�'..��. - �....
is •�:. 'JG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one let/long is sufficient) ]� )
�f� Signature o ' ed Well Contractor Date
6.Is(are)the well(s): L4YCrmanent or OTemporary By signing this foray I hereby certify that the wells)was(were)constructed in accordance
�' with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or CdNo 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 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: / contraction details. You may also attach additional pages if necessary.
For nudtiple 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: `3� (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: ` �,
� (ft) g t,
Division of Water Resources,Information Processin Uni
If water level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (m.) 24b.For Infection Wells ONLY:; In addition to sending the form to the address in
24a above, also submit a copy of:,this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(ie.auger,rotary,cable,direct push,etc.) 1
' Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i Ya Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this foim within 30 days of completion of
granular hypocholrite �,��� well construction to the county health department of the county where
113b.Disinfection type: Amount:
constructed.
,
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013