GW1--06209_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: ,
.
Bill Kenned 14.WATER ZONES'. ..l; ,
Y y FROM TO DESCRIPTION
Well Contractor Name 70 ft. 7.,,, v ft. - ,,,!®�
2834-A ft. ft. �
I45:OUTER CASING(for:in wells)'OR,LINER(1f ap'llcable)
NC Well Contractor Certification Number `'°
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. ft. 6.25 '►n' SDR-21 PVC
Company Name 16:INNER CASING"OR TUi BLNG(ge"othermal'closed loop).F.4-_ 4.,. . ..
�^, /4 „w�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Ij,GSY{v�/'L!d /O/ 787 ft. ft. ; in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.,
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Elliential Water Supply(single) ft ft. in.
❑industriaVCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 ft. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. /a. 6ac
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -`19.'SAND/GRAVELPACK Of applicable), s'="' ' x =.:c
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 :3720.DRILLING LOG;(attach additionatshects if necessary) ..,-.- F '--
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardnessoWroek type,grain size,etc.),s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft a [t. �� s/. i i
ft. ft. ,� -7L
4.Date Well(s)Completed:V 1D f' G/Well ID# 0 fL ` v ft. A tui t) /
5a.Well Location: s-sft /r3 ft l�"l�, J
Cj��V ni�P''L Pg'L JJ ft. ZS\7 ft. ,Cp� i' .;.- -r'1—> ti4..
Facility/Owner Name Facility ID#(if applicable) ft. ft.
069 EOa)a• s .51 ' ft. ft. OCT 2 1 2024
Physical Ad s,City,and Zip 21:
(/ a
4 ni,A 0 !J � ga,� REMARKS TMr.,` x '� 'c' ,' ' , ..
IyiV�y �.Id v7
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 fr—p_,0—a7/� MedWellConctor Date
�
6.Is(are)the well(s): Permanent 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 Lao 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
S.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 I
9.Total well depth below land surface: ir3 (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'and2@100') construction to the following: I
10.Static water level below top of casing: `J (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 oflthis form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: 1
(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
I
13a.Yield(gpm) s_Sn Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the countyhealth department of the countywhere
13b.Disinfection type: Amount: P
Z constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
f .