GW1--02327_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATERZONEs ':• . .
FROM TO DESCRIPTION
Well Contractor Name J O�//ft. /O ft i
2834-A ft. (� ft. e 9°�,
' ;
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR LINER(if'an' licable) '
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 3b ft. 6.25 i°- SDR-21 PVC
Company Name 16.-INNER'CASING OR TUBING(geothermal closed-Mob)
/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: h� -'Qj tg�(!,7(am� 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 ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. ft. In.
esid
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.
FROMROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT o1iNT
❑irrigation 0 ft' 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft. t
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) `
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional,sheets if necessary) ` " l
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 it. r0 ft. F//Kne/-4- tcck
4.Date Well(s)Completed:3`��-01V Well ID# io ft is ft-
t ,�'f�/�J�`i it G
Sa.Well Location: •
/ ft f 0� ft. /j J�('k
` it. ft. wGGf
)2/)f e/ JQ y,ZT- Jr'7,zS7 1 ft. ft.
Facility/Owner Name / Facility lD#(if applicable) ft. ft. A l` i, L.[ �0- }.'- _
el%% i/c- Mel 7oC ft. ft. APR 1 4�M...
�fiT4
Physical Ad s,City,and Zip
4 0PA 7C7,12[9705 m;o ,,.:: t;, P - .,R ,,,l;u..
County Parcel Identification No.(PIN) D'+th..Y:i'.&;
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one laat/long is sufficient)
N w 3-/e-ay
Signature o erti led Well Contractor Date
6.Is(are)the well(s): i manent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or GM copy of this record has been provided to the well owner.
If this is a repair,Jill 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: l 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: 103 (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'and22@100') construction to the following: I
10.Static water level below top of casing: /(/ (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 Iniection 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: f '
(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
13a.Yield(gpm) JD Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: /OnZ well construction to the county)health,department of the county where
constructed. i!
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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