GW1--02946_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD For jeflernalUse ONLY;
This form can be used for single or multiple wells 4
1.Well Contractor Information: 1
Billy Kennedy F1RwMTERZONEs OM TO DESCRIPTION
Well Well Contractor Name ¢� ft. g/ ft i I
2834-A t'v ft. ft. (e
NC Well Contractor Certification Number IS.OUTER CASING(for.multi-eased*ells)OR LINER Of ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 4/02-ft• 6.25 ' in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
��1 //.J� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Rdvt/3^ Ot� t� V ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Infection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El‘rieultural CIMunicipal/Public ft. ft. in.
❑Geotbermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
. ❑lndustriallCommercial ❑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. ft
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Injection Well: ft. tt. '
❑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 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary):. -
❑Geothermal(Closed Loop) ❑Tracer - FROM TO DESCRIPTION(color,hardness,soil/roclt type,grain sine,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)' 0 ft, 5- it• /( d//o ti /_(Gt
4.Date Well(s)Completed o2O'C1.�Well ID# ^ ft p2n7 ft J��U ��'""`e
5a.Well Location:
ota ft. 30 D. t�0'G1 ,
t30 ft. a3 ft. � x-/� ,---.,.-_ -
I+evlr V A i1e_n ft. ft. F P�T'
err � /'� E�,�t�..k,;�.. i ���._,~e.:�
Facility/Owne ame Facility ID#(if applicable) ft. ft.
113 COL Gv'eei< 11i1/'// iel ft. ft MAY I ' 2024
Physical Address,City,and Zip 2 ,-r.r << ,
1.REMARKS .: �lcA.,.,' ".':.'^� : . ,j Urn i
Rp ��A 7/o le 02.3. y C."..V.;3'.;u
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)
1
N W 6 /4Otii/KP ao-QV
Signature"oviertified Well Contractor a, Date
6.Is(are)the well(s): ermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�� with ISA 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 L•nV o 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 0223 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) 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 (in.) 24b.For Infection Wells ONLY:,In addition to sending the form to the address in
24a above, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: rotary construction to the following: i
(ie.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) 6 Method of test: Air 24c.For Water Supply&Injec ion Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite lad well construction to the county health department of the county where
13b.Disinfection type: Amount: _ Z- constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013