GW1--04747_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROM
ONES. DESCRIPTION
Well Contractor Name /10 ft. / ft. �
��`
2834-A ft. /! ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORSL NER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling (9 ft. /p 7 ft. 6.25 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)'
Q��► FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: aoaa.--,t,�Y'l�t'1 _1 Q.'1 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,
Ibnjecctiioon,etc.)) ft ft in.
3.Well Use(check well use):
t17.SCREEN... .`;.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) PfResidential� Water Supply(single) ft" ft. in.
❑Industrial/Commercial ❑Residential 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) -•
❑Aquifer Storage and Recovery ❑Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
rt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)"
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESK CON(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. /O ft. �2' n/2
4.Date Well(s)Completed: ell ID# /a ft. /0 ft' eem ` Pt-- 'lo'lock
J�0 ft. eazz5 ft. wirier1/_ I
/ ft. ft. /
5a.Well Location:
3-err, 60,r , ft. ft. RECEIVED
Facility/Owngf Name Facility ID#(if applicable) ft ft.
ill/7/ Li' lc, &an fe, /i ft. ft. JUL 2 4 2023 .
Physical Address,
City,and Zip 21.REMARKS .-w r�r ' ;t Pr' . ze,s3'1 Irt4 '%
ry:��/�,r)/4 t t Dtf Q/30(3
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 1 "l - %- �� 4..
Signature f ertified Well Contractor Date
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this form,I hereby certtfr 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 ❑No 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:
8.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. ,.ram.� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: aCa, (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@1001 construction to the following:
10.Static water level below top of casing: -/P (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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.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) J 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 /AaZ well construction to the county health department of the county where
13b.Disinfection type: , Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013