GW1--07742_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells •
1.Well Contractor Information:
Bill Kennedy/ -14.WATBRZONES e' .
Y J FROM TO DESCRIPTION
Well Contractor Name ft.
2834-A f 7" /tom •4 IL�`�ll
NC Well Contractor Certification Number 1S..OUTER CASING(for multi-cased+kdlls)OR LINER Of ap cable).
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft 43ft- 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)..; •
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t ' V�p�®06d ft. ft. In. •
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft. i in
3.Well Use(check well use):
17.SCREEN :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural - ❑Mu��nicipallPublic ft in •
❑Geothermal(Heating/Cooling Supply) l idential Water Supply(single) ft ft. In.
�
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT .
FROM TO MATERIAL E n:PLACEMENT METHOD do AMOUNT
❑litigahon 0 ft* Z0+ ft' Bentonite Hydrate chips in place
Non-Water Supply Well: -
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft. '
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ARTERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FRO TO D':aris tN(color,hardness.sootroek type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) V ft 1 S—ft.
4.Date Well(s)Completed:/p-�c+ - Well ID sn 0`,30 tt
ft- 4 - e- base-
5a.Well Location: ® ft. 9 7� �` •
1�44�%°�
ft. rt. )
Facility%Owner Name ' Facility 1D#(if applicable '° " d'' '` `
_ 1t it, i
249 7& hii,veta Pit/km , ft. ft. DEC t) = 2023
Physical Address,City,and Zip 21:RE.:i3ARKS `
47 PlideV/4A 7 .7901811•3 . ....-... . . . . . . .
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
o-30
N W Si edified Well Contra to - 3
6.Is(are)the well(s): liggimanent 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 E1111 copy of this record has been provided to the well owner.
If this is a repair,fill outhnoten 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.
S.Number of wells constructed: / construction details You may also attach additional pages if necessary.
For nndutple 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 lifi (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If-different(example-3Q200'and 2©100)r10 construction to the following:
i.
10.Static water level below top of ea 1S°sing: � (ft) Division of Water Resources,Information Processing Unit,
If niter level is above casing,use"+" 1617 Mall 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 1 ;
(i.e.auger,rotary,cable,direct posh,etc.) ; I
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 57°' Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
type: granular hypocholnte / Z well construction to the county health department of the county where
13b.DisinfectionAmount: C
constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013