GW1--02334_Well Construction - GW1_20240410

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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 1a:WATER ZONES ` : i
FROM TO DESCRIPTION'J
Well Contractor Name 3 15-ft. 3017 ft. pole
2834-A ft. , ft. ( /"
NC Well Contractor Certification Number 15:'OUTER CASING(for multi-cased sells)OR LINER(if ap]tcable),
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling aft g�.it 6.25 in SDR-21 PVC
16:INNER CASING OR.TUBING`
Company Name
(geottiermal closcd-loiip)
} FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .00J 1 y ft ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SITE -THICKNESS• .',MATERIAL
DAgricultural ❑Mu
ft. ft. in.
��nicipal/Public
DGeothermal(Heating/Cooling Supply) Lagesidential Water Supply(single) R' ft .in
❑lndustrial/Commercial DResidential Water Supply(shared) 1&GROUT
FROM TO MATERIAL Et►IpLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: 0 ft 20+ ft Bentonite Hydrate chips in place
❑Monitoring ORecovery ft. ft •
Injection Well: ft, g,
❑Aquifer Recharge ❑Groundwater Remediation 7,19.-SAND/GRAVEL.PACK(if applicable);
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD-
ft. ft
. ❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
.20;DRILLING:LOG(attach'additional sheets if necessa❑Geothermal(Closed Loop) ❑Tracerns '` i:
FROM TO DON(color,hardness,son/rock type,grain she,etc.)...-
❑Geothermal(Heating/Cooling Return)t ❑Other(explain under#21 Remarks) a ft la it `r 1
4.Date Well(s)Completed: t1�.-�•7 talWell ID# �� ft. 3'O ft t��'�J1 S►T?ti - ( -
Sa Well Location: 3" . 1-413 D' ii-trd/'oCc/� 1, : Ei—. - e".,K. f:. ;; ,
ii
FacilI ity Owner Name Facility IV/(if applicable) f t i ft. r R V 024
ley PAL/ Ad ft. ft. Infs'1artiUrn Prr:7 fii N
ig, i).1k,
Physical Address,City,and Zip ft ft. C•iY'.. ... 0(.
Cla /i, :;2l:ItEi11ARKS"
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient)
,3. f(ca05-",a_ N 7? swig/Jig w a-ls=a /
�� • Signature Certified Well Contractor Date
6.Is(are)the well(s): laf rmanent or OTemporary
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO 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:
8.Number of wells constructed:
/ You may use the back of this page to provide additional well site details or well
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'
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�
9.Total well depth below land surface: t�C (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@l00) construction to the following:
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 (m,) 24b.For Infection 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 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) j
• Division of Water Resources,,Underground Injection Control Program,
' FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / 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: /le pe_ 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 Watei Resources
Revised August 2013
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