GW1--07743_Well Construction - GW1_20231204

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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:
Billy Kennedy FRRO WATER ZONES DESCRIPTION
"TO RIPTION
Well Contractor Name 75'ft. ft. ,675pot
2834-A ca ft. Cis—ft. s—..,,
NC Well Contractor Certification Number .15.OUTER CASING(for multeri
i-c wells)OR LINER(if ap licable)
FR01%1 TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling 0 ft- 6,g' ft- 6.25 in- SDR-21 PVC
Company Name 16.,INNER'CASING OR'TUBING(geothermal closed-loop)
r� 2 �I'1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Q..V01v —Ot9O°27 e 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 ft. TO DIAMETER f SLOT SIZE • THICKNESS MATERIAL
in.
❑Agricultural ❑Munici blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft In.
,
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irigation 0 ft. 20+ it. Bentonite Hydrate chips in place -!a b c
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 ❑Sgljnjty Barrier ft.
TO - MATERIAL EMPLACEMENT METHOD
ft. ft. +
❑Aquifer Test ❑Storniwater Drainage
ft. ft. i
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiiirock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) /� ft. /L ft. dh'
4.Date Well(s)Completed:f 1 7 a3 Well ID# `� f ti rci_;t
® � 1 �-t. 49
5a.Well Location: ft. ft.
Apr (1rea50/1 ft ft. tom. .T
Facility/Owner Name Facility ID#(if applicable) ^• „Y r 1'�
n � ft. ft. nCr � _ 2t'�J
t,310 j� yo U r1 I�O( ft. ft.
I
Physical Addres City,and Zip 21.REMARKS tins :-2
AO o'h 77 9OP,?a26Oa_
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one'at/long is sufficient)
N W I/-9-023
� Signs • •f Ce ' ed Well Contractor Date
6.Is(are)the well(s): agermanent or OTemporary By signing this form,I hereby cernfy'that the well(s)was(were)constructed in accordance
with 1 SA 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 QNo 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: / 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 i .
9.Total well depth below land surface: /c2 / (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: I
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service:Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6.25 On-) 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 constmction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) I 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Air 24c.For Water Supply&Injection Wells:
(gP ) Method of test: .. Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount %Ode well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013