GW1--04752_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 TO
DESCRIPTION
Well Contractor Name jft. akr ft. f�`doet
2834-A (�_t-ft. boos ft. /v r
15.OUTER CASING(for multi ai ed'wells)OR LINER-(if'ap licable)
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 35- ft. 6.25 in* SDR-21 PVC
Company Name 10.INNER CASING OR'TUBING(geothermal closed-loop) ' ,
n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a ^ 000y� 2/�C(/ 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
ft ft in.
[Agricultural ❑Municipal/Public __,_
0 Geothermal(Heating/Cooling Supply) Eirgidential Water Supply(single) ft ft. in.
❑Industrial/Commercial DResidential Water Supply(shared)
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 it
DAquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) . ,
[Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it ft.
[Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)',"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solirock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 3 ft. d�
4.Date Well(s) l�
Completed: -1S"- lD Well # ft. aO ft. A 5 �
DO ft a-- ft. Ajj/dike rt 4 e k
5a.Well Location: �� ft. /® ft. i/ i'� 1
.Ca G-�
a i to y k P ft ft. CI
t.:I i ® M
Facility/Owner N e Facility ID#(if applicable) ft ft. t %L..L ® l�tel
3 7'/ Ara 1 avid L IV ft. ft. It UI 9, 4 2023
Physical Addresw City,and Zip
i 2L;REMARKS=h'
,,ail I 1 t 76S'i'/O( a 7 informe4itna PrfIcasigng link .;..
County Parcel Identification No.(PIN) 1c.VG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W �� rsw & - --
Signatur fCertifiedWellContrac41 Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certffr that the wells)was(were)constructed in accordance
with 1511 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 lEt 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: �I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /e �. (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: Leer- (ft.) Division of Water Resources,Information Processing Unit,
Ifwaler 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
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) 9-5— 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 well construction to the county health department of the county where
13b.Disinfection type: Amount: '3 C�Z
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013