GW1--06916_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD For lntenral Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROM ATE TO RZONES DESCRIPTION
Well Contractor Name 7 r fit. 7 a./ft. 6
2834-A ..77 ft. S�
15.OUTER'CASING.(farMMahe•cased'wellsIfOR-LINER'((fap teable)`:
NC Well Contractor CenifigtionNumber FROM TO 1 DIAMETER 1 THICKNESS MATERIAL _
Kennedy Well Drilling ® it. 40 ft 6.25 i 111• SDR-21 PVC
Company Name I6.'INNt;it:CASING'OR I UALNO(geothermal closed-loop);;: • '
�" FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: krC2/(p q ft. it. I In.
List all applicable well permits(i.e County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 176 SCREEN'.'
Water Supply Well: FROM I TO DIAMETER SLOT SIPE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public fit hi.
OGeothermal(Heating/Cooling Supply) EIGIdential Water Supply(single) ft ft" in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 1S:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Wate gation Supply Well: 0 ft' 20+ it Bentonite Hydrate chips in place
❑Monitoring ❑Recovery ft. it /f knef4
Injection Well: ft. ft. f
❑Aquifer Recharge ❑Groundwater Remcdiation :19.SAND/GRAVEL PACK(if applicable) ..-..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft fit
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
°Experimental Technology 0 Subsidence Control
20:.DRILLING LOG(attach'additional sheets if necessary)4, -
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,roll/rook type,pram she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D. it. ft• ' t-
4.Date Well(s)Completed:/0—? ?1/Well ID# �'r fit .
/ -:: 444e�% e�
5a.Well Location: /`� ft ft. 1 /� �G
�>�//! Gf , 377ft ft
Facility/Ownera Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zi l� l `i 7024
P
/�/y)^o
County Parcel Identification o.(PIN) `,r':d'.,.:1 •%JU
5b.Latitude and Longitude in deg ees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) i
N W gna re rtili3W �o.4
(
�� Si na re e e ell Contractor Da e
6.Is(are)the well(s): C I rmanent or OTemporary By signing this form,1 hereby certify that the wells)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 Aivo copy oft is record has been provided to the well owner.
1f this is a repair,fill out known well.construction information and explain the nature of the
repair under#2I 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 hnection or non=water supply wells ONLY with the sante construction,you can
submit one form. .� SUBMITTAL INSTUCTIONS '
�.9.Total well depth below land surface: 03 (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(0200'and 2Q100') construction to the following: .
10.Static water level below top of casing: -_ 1/O. _ _ _-_(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'4" 1617 Mail 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
rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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 24e.Far Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: / ®� well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of WaterI Resources Revised August 2013