GW1--03894_Well Construction - GW1_20240628

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 DESCRIPTION
Well Contractor Name C1�//_n ft. ft /���111,1.
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ble)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling () rt. ,lea It. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Y ` O�D��O� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit It: O�er;4112 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: mom - - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑M ipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation iga Supply Well: 0 ft. 20+ it" Bentonite Hydrate chips in place
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAI. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier I ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.son/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ) ft. ,S' ft. I`'G�ik_ - ,r.'t
4.Date Well(s)Completed:-�.19 -agVV ed dD# S- ft. 30 ft. e�i'Yl
5a.Well Location: 30 ft. s- ft. L /._� i
rise;darker
er Alked ifs"ft. �� fL yJ '°
ft. ft.
Facility/Owner N Facility ID#(if applicable) ft. ft f" r' i
G 1 a civet... -tic& tJy LA/ «. ft. + •_`.,--
Physical Addrejs,City,and Zip 21.REMARKS JUN 3 8 2024
Raitofoi/d4 77k32.37y)G
County Parcel Identification No.(YIN) irefvr P. .i'al*-r^ar ,1 UM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W � 4'/( 4t3..SignalC red W Date
6.Is(are)the well(s): if rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 01Yo 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 wit the same construction,you can
submit one form. /f SUBMITTAL INSTUCTIONS
w 9.Total well depth below land surface: e_ (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®100) construction to the following:
10.Static water level below top of casing: (g.) 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
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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSr ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) )U Method of test: Air 24c.For Water Supply&injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochkxite well construction to the county health department of the county where
13b.Disinfection type: Amount: 00 L
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013