GW1--03167_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO 7 DESCRIPTION
J t/
Well Contractor Name /�/)ft. / $ t p,,
2834-A D. . a-
(Welt Contractor Certification Number nc
15.OUTER CASING(for multi-cased wells)OR LINER(if ap able)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a ft. air ft 6.25 SDR-21 PVC
Company Name I .INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
..5M 2.Well Construction Permit#: .. a3 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM '11) DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft in
❑Geotheral(Heating/Cooling Supply) 2dential Water Supply(single) ft ft- to
m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. fc
20+ Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft ft
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed TT,,,,,..,, ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Loop) FROM TO DESCRIPTION(color.hardness,sou/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft Li ft. t,r-
^^
4.Date Well(s)Completed _a-osilVVell II)# ft is ft. 2 s
is- ft. 303 ft. IGJ(Et
a /L e:2
5a.Well Location: / ft. ft.
11: 6Cirn Ce ft. ft r
Facility/Owner Name Facility ID#(if applicable) ft ft.
c 7 S ✓/Yi 44 f /ur ,q ft. ft. MAY Physical Address,City Zip MAY 21 2024
21.REMARKS
it.
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)
N W irtZConr� Sin Date
6.Is(are)the well(s): L�fYermenent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Er 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 injection or non-water supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30,5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2(41001 construction to the following:
10.Static water level below top of casing: ap (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 Inlection Wells ONLY: In addition to sending the fonts 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.)
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
13tr.Disinfection type: granular hypocholrite Amount: /60 y 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 Water Resources Revised August 2013