GW1-2023-02890_Well Construction - GW1_20230418

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 DESCRIPTIO
N
Well Contractor Name ft ft. IPA l
2834-A It. ft. I �
NC Well Contractor Certification Number
15 OUTER'CASING:formulU=cased:weIIs'OR'LINER: -a"Qcable'.
FROM TO DIAMETER� THICKNESS MATERIAL
Kennedy Well Drilling D ft 33 ft. 6.25 in. SDR-21 I PVC
Company Name &'.INNER CASING'OR-TUBING eothermal closed-loo - ` '
G J FRODI TO DIAMETER THICKNESS AMERIAL
2.Well Construction Permit#: fL ft. is
List all applicable well permits(t.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 47,SCREEN, "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MMu/unicipal/Public ft- ft in.
❑Geothermal(Heating/Cooling Supply) [3Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial OResidendal Water Supply(shared) Ag.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
fc it.
❑Monitoring ORecovery
Injection Well: % ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.-SAND/GRAVEL PACK if a licable ._
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM To IA MATERL EMPLACEMENT DfETEOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
20 DRiLLUYG-LOG attach addlttoutal sheets ifnecess"
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soNrock type,wain fize,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Retrains) / ft, S., fL
y� '��,3 J ft. V ft,
4.Date Well(s)Completed: ,7 Well ID#
ft. rt.
Sa.Well Location: f ft ft.
U�P`i►1�! �(�L/r yt S ft. ft. - --
Facility/Owner N ne Facility ID#(if applicable)
& ft.
ft. ft. V APR 11 S 2023
Physical Address,City,and Zip '
•21`REIV ARKS
County Parcel Identification No.(PIN) Li
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
// Signa Certified Well Contractor Date
6.Is(are)the well(s): A ermanent or []Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
� with ISA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RNo 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 bacof this page to provide additional well site details or well
8.Number of wells constructed: construction details. ,tu 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: t3(� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2@100) construction to the following:
10.Static water level below bop of casing: LIS` (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test* Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forms within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: > well construction to the county health department of the county where
l.�(�'
constructed
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013