GW1--04498_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD , For Inland Use ONLY:
w
This item ma be used for single«nadiiple walls
1.Well Contractor Itliennialou:
Billy Kennedy ItWATER MO DESCRIPTION
Well Contractor Name n ft. rwi
2834-A rt. st t —i
NC well coon:emus cetufteattoa Number '15.OUTER Alfa tier lint .aaed watts)OR l: 1411R Or as lkaate)
FROM TO DIAMQrER TRICICteES9 MATERCAL
Kennedy Well Drilling iOsa cat! ft. 6.25 Ia. SDR-21_ PVC
Company Name ,1L INNEROR TUBING(gunhenstal daseddeeM
J ?� FROM TO DIAMETER TWCYNESS MATERIAL
2.Well Construction Permit 4: i7 1/ ft. ft. Is.
Lien all applicable mg/permier fine.County,State.Yeusmce eaten.etc.)
ft. ft. ill.
3.Well Use(check well rase): II.SCREW ,
Water Supply Well: FROM TO » mar SIZE TRICE N 18 MAMMAL
i?fgricultural OMunicipai/Public ft. it. is
°Geothermal(Heating/Coohng Supply) Eillistiel Water Supply(Single)
ft. ft. tn.
❑hehtstrial/Cotttnlercial OResideotial Water Supply(Shared) IL G> ? •
PROM TO MATERIAL* FRa1..ICEMENT METHOD a:AMOLTrT
nhrwder Supply Welk p fr. 20+ m 6entonite H to ace
Ohlecitoring °Revery ft.
/D bvIe
Injection Well: D. n-
°Aquifer Recharge °Groundwater Rcmcdiation 1+.SANDIGRAYIFL PACK snatlablel
❑Aquiter Storage and Recovery °Salinity Barrier PROM TO MATERIAL aMPt.ACIEMHATMFThiOD
ft S
GAquifer Twat OStormweter Drainage
-
rt n.
OlxperimemxiTechnology °Subsiden:eCamel
2$.DQILLltiC LOG(attach eddMMul ebeeb)t aetesser)
❑Geothermal(Closed Loop) OTraccr FROM To DESCRIPTION tealor,kaftan,aonhaettsoc,MR SW MO ,
OGootheftitai(HeiltinWVCaoling Rehm) °Other(e tplain'Under#21 Retnarke) 0 ft- 3-- "' ill:••f /b
fi.4.Dete Well(a)Completed: 6, €R toll S' /a /.aye eta
/0 it. 4 ft. ,6edfocst- — 41/.e. t.` ._ ,
5a.Well Location: � / fit_ ft.
t tit /1-4 .x.. tt. n . . f.
Facility/Owner Name Facility IDS(ifappdcable) I-
st7S- i ••-....-`: tr..- ' tt-)y 4.. ,
� /� ft. ft.
"Oe- /�� n. ft. '--7 U L 3 0 2014
Phe..4•2 City,A- 7`a -/ 77 2L R�11 iIRXS I r.fr,:'T;.t..,:c, :r. .,-yl.c:,. ,Usgif
County Parcel ldentifeatioe No.(PLN1 riAt: 2C-to }
5h.Latitude and Longitude In degrsn(minatta/sccends or decimal degrees: 22.Certification:
(ii well field,one 1uLLmg is sutliviettl)
N w C-av-at// S and nil I>a�
6.Is(are)the well(s): f29(iaoent or OTemporary Ay signing this form I hereby err*,that the walk's)was(were)constructed in accordance
with I SA NCAC OX.0100 or 1 SA NCAC OW.0300 Well Caaswction Standards and that a
7.Is this a repair to an existing well: DYes or OWo copy of thb record has been provided to the weU owner.
It this is a repair.fill out know.:well construction I.jo nratimt and explain the nature of the
repair under e21 remarks section or on the back of this fors. 23.Site t&aaram or additional well detsIs:
L Number of wells constructed: , You may use the back of this page to provide additional well site details or well
cot attnetion details. You may also attach additional pages if necessary.
For mu114de Warden or mn.weter supply wvllt ONLY with the same toaarna1lua.you ran
mooch~form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below lard surface: 3,1,3 (ft) 24s. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all&PNts!I-different(cnmrgvle-WOO'and 2®100) caasttuction to the following:
l0.Static water level below top of casing: /( (ft,) Division of Water Re soarcee,Information Processing Unit,
If water level it above coxing,use-+- 1617 Man Service Center,Raleigh,NC 27699-1$17
11.Borehole diameter: 6.25 (n-) 24b.For Infection Web ONLY: In addition to sending the form to the address in
rota 24e above.also submit a copy of this firm within 30 days of completion of well
12.Weil contraction method: ry construction to the following:
(Le.auger.teary,cable.direct push.etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769941436
13a.Yield(gpm) pl. Method of teats Air 24e-For Water Supply&Injection Wells:
Also submit one copy of this farm within 30 days of completion of
136.Disinfection type: praiser h podX*ite Amount: t Q Z well construction to the county health_department of the county where
constructed.
Form GW-1 North Carolina Department of Ilmiranment and Natural Resources—Division pf water Resources Revised August 2013