GW1--00339_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells I
1.Well Contractor Information:
Bill Kennedy 14s'�vnTER.ztJlvEs
p FROM TO DESCRIPTION
Well Contractor Name /er it. /Q C ft. /�y5�,vai
2834-A ft. /J R- i
NC Well Contractor Certification Number 7 15 OUTER'CASING(for mnititieasedireIls):ORLDIER°(if ap lkable)
FROM ' TO DIAMETER THICKCNNESS MATERVAL
Kennedy Well Drilling 0 ft. .14 ft* 6.25' SDR-21 PVC
Company Name 16.INNER CA G ORTUBING(geothermal closed400p) -'
' ` �' 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft, in.
List all applicable well permits(La.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO. 'DIAMIBtii`"SLOT SIZE- THICkNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft' to
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. it i°'
❑Industrial/Commercial ❑Residential Water Supply(shared) ]ti;GROUT
FROM TO MATERIAL EMPLACEMENT EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft- Bentonite Hydrate chips in place /Vix,
Non-Water Supply Well:
ft. ff • 5
❑Monitoring ❑Recovery
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EDiPLACEMENTMETHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
2O.DRILLINfG`LOGIattackadditiontil sheetilf necessary)
OGeothermal(Closed Loop) YJTracer FROM TO - DES IPTION(color,hardness,sell/rock type,grain size,eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ftt.. r v,
4.Date Well(s)Completed: // ft t23well ID# �ft. ft. i
5a.Well Locatio :
II'' ft ft.
�� ��. _. 41- s ft. ft. 1-‘t: ,moo i ��
Facility/Owner Name ,� / F cility.ID#(if applicable) ft
f3 41 1Y'I��e.- ✓mot ft. ft. IU N 1 202�4
Physical Address,City,and Zip �21sREMARKS .1fsC,ir.. af"i•^, i.,.T.z., t4+i�aJ
0Vnei 000
0.`,� � DWOB0434 4 County Parcel Identification No.(PIN)
• 5b.Latitude and'Longitude in degreesfminutes/seconds or decimal degrees: 22.Certification: •
(if well field,one lat/long is sufficient)
N W 1 //as023
Signature edified Well Contractor, Date
6.Is(are)the well(s): LlYermanent 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 21 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 nun-water supply wells ONLY with the same,construction,you can
submit one form. SUBMITTAL INSTUCTIONS 1
�
9.Total well depth below land surface: 47 02--.5 i
(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 00'and 2(1100) construction to the following: P
10.Static water level below top of casing: /f (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in-) 24b.For Injection Wells ONLY: 'In addition to sending the form to the address in
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I'
Division of Water Resource;Underground Injecdon:Control Progson4
Mall Se
FOR WATER SUPPLY WELLS ONLY: 1636 Marvice'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: Air 24c.For Water Supply&Injection n Wells:
Also submit one copy of this form within 30 days of completion of
granularhypochoirite well construction to the countyhealth department of the countywhere
13b.Disinfection type: Amount: 4/.1,� constructed I
Fenn CW-1 . North Carolina Department ment of Environtnnnt and Natural Resources-�-Di vission of Wate Resour Revised Angcst 2013