GW1--04738_Well Construction - GW1_20230724

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy ;14.R WATER ZONES OM TO DESCRIPTION
Well Contractor Name io ft. .ficrl ft. ^ey:�
2834-A go ft. 49, ft. N
elk
NC Well Contractor Certification Number 15.OUTER CASING(for multi .. wells)OR LINER(if applicable) `
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 3 ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�� 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): :17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public it ft. in.
M
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. In.
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DES ON(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. a_ ft. Iv,t
4.Date Well(s)Completed: 7'Cv 3 Well ID# a ft. it. O _� G f�
5a.Well Locatio •
0 ft. i 5 ft. �Aeifor,.�
/�, J !o ft. ! ft. �.�..+,'�
, l//�V' �"f-_'tom e 7
/ J-.'r, ft, ft. r 1 11.-10 E i 4r Y-n
Facility/Owner Name Facility ID#(if applicable)
S7 Ilia 1./ ft. ft. JUL 9. A. 2023
o? Il /t:-/C( ,Or. ft. ft. t a
Physical Address,City,and Zip 21.REMARKS:. jflftiyar41.+l °P,f` «�' r:
Ao�te_ 0000e0 CO _- .-- INICuy �
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat./long is sufficient)
N W ' ^ ',/ /�,k e 7`Cp-.23Signature o_0- ' ed Well Contractor d
Date
6.Is(are)the well(s): ermanent or OTemporary By signing this form,I hereby cert fy 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 ONo 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
9.Total well depth below land surface: 1a5-- (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 2@100) construction to the following:
10.Static water level below top of casing: a (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 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:
(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
13a.Yield(gpm) a Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite �1 well construction to the county health department of the county where
13b.Disinfection type: Amount: /t/0,
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013