GW1--06208_Well Construction - GW1_20241021

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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: ,
14.WATER'ZONES ¢;
Billy Kennedy FROM TO DESCRIPTION = .
Well Contractor Name 670 ft 7cft. S7I0ipett
2834-A fL ft
NC Well Contractor Certification Number '15.OUTER'CASING(far:multi-cased.wells)OR'LINERdf apnl cable) •
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ® ft 11 ft 6.25 in' SDR-21 PVC
Company Name '.162IIVNER CASIN OR,TUBING"(geotherrital closed loop)-.1- ;; .. t4,.e�' ::-
�� - ooO�/��� FROM TO DIAMETER 'THICKNESS MATERIAL -
2.Well Construction Permit#: ft. ft. ; in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. ! in.
3.Well Use(check well use): 1iiscRETIV
Water Supply Well: FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft It. in.,
❑Geotheal(Heating/Cooling Supply) BTfesidential Water Supply(single) ft. ft. in.
rm
❑lndustrial/Commercial ❑Residential Water Supply(shared) '--
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,:19.`SAND/GRAVEL PACK{if applicable) ;<;' `
FROM TO MATERIAL EMPLACEMENT METHOD ,K
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
DAquifer Test CStormwater Drainage
ft. ft. I
❑Experimental Technology 0 Subsidence Control ;ya DRILLING LOG(attach additionahsheets if necessary) ..
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft. ft. /Der eiil/kr. fit.
D s ft 30 ft d/ev
4.Date Well(s)Completed: /'is-t1/Well m# 30 ft �n ft �,�� I
5a.Well Location: ft. _).. ft. z5 e _
�G ln+�O(/ S p✓l & OlijO ro i 'P.;_ . �.
Facility/Owner Name Facility ID# ' applicable) ft. ft 1LO A
ee 447 Aft l�ba✓on ft. ft. OCT1 `+
Physical Address City,and Zip :21.REMARKS',,' ° , 1 c�-.- r t� <' l ..<
ita.N. PA 76 a �9B7$'tro D }
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) C�[^�
N W / < °c."t
y
Signature o • ed Well Contractor Date
6.Is(are)the well(s): ( rinanent or OTemporary By signing this form,I hereby certify that.the well(s)was(were)constructed in accordance
with 15A 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 ❑moo copy of this record has been provided toy 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:
S.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
submit one form. ^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1.13 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2Qa 100' construction to the following: j
10.Static water level below top of casing: /5.'- (g.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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
(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) 50 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypothlorite well construction to the countyhealth department of the countywhere
13b.Disinfection type: Amount: /R-oy
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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