GW1--05276_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD ForintemalUse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.
WATER Z ONES DESCRIPTION
Well Contractor Name ,i.j1/4ft. la[-ft, c j ^
2834-A I v��" ft. 7 JJ ft. 'mil"
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable) '
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling e ft. atO 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#: Ais-p Li
1 ft. ft. in.
List all applicable well permits(Le.County,State,Variance,Injection,etc.) ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑MunicipalfPublic
in.
❑Geothermal(Heating/Cooling Supply) l idential Water Supply(single) ft. ft.
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ it Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
DMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -. ..s
FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
:Experimental Technology 0 Subsidence Control 20.DRILLINGLOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. Lifft. G( kr'
(
4.Date Well(s)Completed: 7 - Well DO1 �s ft L(�/ rock_
5a.Well Location: /c ft. -00 1t ,/J 14e crl G/_
360 ft. �5 ft. /6f A� -min it
6-flv 4- 6� 'a �Pv,a5e ft. ft. _
Facility/ er Name Facility ID#(if applicable) �'„ a 2'"'is`••' ..A:',--
ft. ft. A.".o 4.. .,,r C.Y i v,...
TLf) /I&V D2 ft. ft. AUG ':.2023
Physical Address,City, d Zip
/�/ ^�`� -31,RF.MARKR?i�s' ,_ ,_ .. ... _..
/'" oot�t� ©O(/(7iO2l�/ -..,,..:),n 3rnre�,.ti'11 UnI
lI'r -'
County Parcel Identification No.(PIN) .'f ill n-OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) �7
N w A. _�/ �� -P4 /-�
�_/ Signature o mortified Well Contractor U Date
6.Is(are)the well(s): O'Permanent or ❑Temporary By signing this form,I hereby certify 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 td1Vo 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
8.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. t �I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J V 5' (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: .30 (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
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) 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 well construction to the county health department of the county where
13b.Disinfection type: Amount: a tJ-
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013