GW1--04751_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:
Bill Kennedy 14.WATER!'ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name ct ft. Ai g ft. ry c�Cc-1,I��,�
2834-A ft. � ft.IS.
IS.OUTER CASING,(for multi-eased✓wells)ORLINER(If rap lleabk) •
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft• 3c` ft• 6.25 in. SDR-21 PVC
Company Name 16 INNER CASING OR>EUBING((eothermal.closeddoop) -
�+,n�11 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 90t2 dX ' 0 c?e I(p 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 r'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) Gilltgidential Water Supply(single) ft ft in.
❑lndustriaUComlmercial ❑Residential Water Supply(shared) .aS♦'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20+ ft. Bentonite Hydrate chips in place
ft. ft
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stomiwater Drainage
ft it
❑Experimental Technology ❑Subsidence Control :20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilirock type,grain sire,etc.)
OGeothermal(Heating/Cooling+ Return) DOther(explain under#21 Remarks) () ft' I ft.
4.Date Well(s)Completed:CY"-!J ` Well KW `t ft, _ ft ile Re"s
5a.Well Location: as-- ft 1 r-rt• /_ e 1#
f 1 _ ft. �7 ft. f.A
AJ'tO e s'1.J' Le 1 ft. ft. L a�E~a
Facility/Owner Name O Facility ID#(if applicable) ft f •i 0
3.7 ge/ci Ole, t+,A/ ft. ft. JIJL 2 A 2023
Physical Address City,and Zip 21°REMARKS:.
mild(7/ 76S7/9.634I/ infor: . l.vn Pr^ ;�Urva
County Parcel Identification No.(PIN) "("''
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if welt field,one latflong is sufficient)
N W /< - ,
Signature oP ertiWell Contractor Date
6.Is(are)the well(s): BPCrmanent or ❑Temporary By signing this form,I hereby certij,that the wells)was(were)constructed in accordance
�.,,,� with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or J2I copy of this record has been provided to the well minter.
If this is a repair,fill out known well constrvctton 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: c2-6,i— (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 22@100') construction to the following:
10.Static water level below top of casing: a- (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 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 MaIl Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) pZ Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this four within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: Jfp Oz_ well construction to the county health department of the county where.
constructed. 1
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August2013