GW1--01701_Well Construction - GW1_20240315

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j'
This form can be used for single or multiple wells '
1.Well Contractor Information:
BillyKennedy14.WATERZONES , I:ii .
FROM TO DESCRIPTION
Well Contractor Name ?(.2
O ft. 7,2...
t�ft.
2834-A ft. ft. .j I
NC Well Contractor Certification Number OUTERCASING((or multi-cased wells)OR-LINER:'(if ap iicable)_
FROM TO DIAMETER I 1 THICKNESS MATERIAL
Kennedy Well Drilling 0 ft tic/ ft• 6.25 ; SDR-21 PVC
Company Name 16.INNER CASING OR TUBING'(geothermal elosedluop) .
�^a' / FROM TO DIAMETER I I. THICKNESS MATERIAL
2.Well Construction Permit#: QUX -mo o a(ea r ft. ft. iin.
List all applicable well permits(i.e.County,State,variance, njection,etc.) ft. ft. I
in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M_ u��nicipal/Public ft. ft. I
❑Geothermal(Heating/Cooling Supply) 8itesidential Water Supply(single) n ft in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) lL GROUT`. . . "... . ...' ._ _ .
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft 20+ ft Bentonite '- Hydrate chips in place
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery .
Injection Well: ft. ft.
❑Aquifer•Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)' .. - . . ..
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIALft. ft I ' EMPLACEMENT METHOD
❑Aquifer Test ❑Stornwater Drainage p I
ft. ft. ! I
❑Experimental Technology ❑Subsidence Control 20.DRILLING:LOG.(attach additional'sheets if necessary) . -. -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.sell/reek type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) o ft ` -- ft of r/
4.Date Well(s)Completed:y`t `a-9Well W# 5-- ft. /se ft. a
tell-5&A5a.Well Location: �� ft ?© ft /fr ftVi1� ft. . .YY.'��k_
GYfri ! H-c�P.§ •pet-ft. 1;3 ft. ✓l �"CcG"
Faoih /Owner Name ✓J Facility IDN(if applicable) V x 7 L7 ,,"'p -; ,
tole ,00 lily t zs ft ft -1. �.0I, t t 4 ' ;:
rt ft I, II' ^A AR
Physical Ad City,amp Zip 21.=REMARKS: I MAR 51024
An AffeitOt1 Toigi?ems` ' I 1Rfi�-1
County Parcel Identification No.(PIN) , '. w�2
D'A5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1 '
(Swell field,one lat/long is sufficient) 22.Certification:
ii i�N W
�_�
� Signature,1 edified Well Contractor I Date
6.Is(are)the well(s): fPermanent 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 i3ILo 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 I
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 at ch additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one foam. ^' 22 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ) (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 I
10.Static water level below top of casing: 0 _ (ft.) Division of Water Res I nrces,Information Processing Unit,
If wader level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
I!
11.Borehole diameter: 6.25 (jn.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
rotary24a above, also submit a copy ofi this form within 30 days of completion of well
12.Well construction method: construction to the following: 1 I
(Le.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
Air 24c.For Water Supply&Injection(Wells:
13a.Yield(gpm) � Method of test: � ,
Also submit one copy of this form within 30 days of completion of
granular hypocholrite Amount: well construction to the county health department of the county where
13b.Disinfection type:
��� constructed l I
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013