GW1--01017_Well Construction - GW1_20240209

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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 14:.WATERzoNEs ;,i • ..
FROM TO DESCRIPTION
Well Contractor Name 3S`ft. 36, ft .
il_„ i�
2834-A zee ft. eS— ft. f e.j
�7,�
NC Well Contractor Certification Number 15.OUTER CASING(for.m tiVased-wells)OR LINER(if ap licable)..
FROM TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling d ft' 026' ft 6.25 I in. SDR-21 PVC
16 INNER CASING OR TUBING(geothermal closed-loo'
Company Name ^ /� J � p) ` : `'
2.Well Construction Permit#: a4- 0000 13 FROM TO DIAMETER' THICKNESS MATERIAL.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) 0 ft. /fir tt. e� In �•_! �O ��J�
ft. [J ft 7 �7h (/
3.Well Use(check well use): 17.,SCREEN _ !:'.
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) 136stdential Water Supply(single) ft. ft. in.
0 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:
❑Monitoring ❑Recovery ® ft 1/.( . por arIR 4/,i- "mit
Injection Well: ft ft.
DAquifer Recharge ❑Groundwater Remediation 19.'SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG,(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(coin hardness,soilrock type•grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) Q ft. ft G�a� _I,d,f
/
4.Date Well(s)Completed: )°—t a/Well ID# ft /a ft sa s, � _4 i . ,
l'br ft. /,9J ft. ay tort'/- [ R 4.=,.'�•h f.• `i�),.
5a.Well Location: ft. ft. ✓ G
5c;t5&p k Ut/oa ecp ft. ft. ' rEB 6 Q 2024
Facility/Owner Name Facility ID#(if applicable)
4 /� () ft. ft. tfl,fcrrra;itrn P.y; ,:2 l�tA
1341 Pu/' ✓(�/r a i g ft. ft. DWCT8O(
Physical Address,City,and Zip
41h/Oi e70( c'we,y -Pi g lis/ _/'lee- .�/ a.*
County Parcel Identification No.(PIN) F/ti
r ____11.., O)e' Weztia ''
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certtfi lion• 1
(if well field,one lat/long is sufficient) p
N W 4 /<e, f_ aq
/� Signature ertified Well Contractor Date
6.Is(are)the•weli(s): lTrermanent 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: rGYes or ❑No copy of this record has been provided toI 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 i'
• submit one form. SUBMITTAL INSTUCTIONS : '
1
9.Total well depth below land surface: f.6.5-- (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'and 2@100`) construction to the following: ; '
10.Static water level below top of casing: Sr (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLYd In addition to sending the form to the address in
1 O1 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 15— Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this foiml within 30 days of completion of
granular hypochalrite /�� well construction to the coup health department of the countywhere
i 13b.Dicinfanton type: Amount: ty eP
I constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water+Reources Revised August 2013
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