GW1--05920_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy14.WATERZONES.
FROM TO DESCRIPTION
• Well Contractor Name azet a7Of` 1 _
2834-A 39.0f` l f` per,
•NC Well Contractor Certification Number 16.OUTER CASING:ffor.muw ed.wells)OW`LINER:(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft- 39 ft• 6.251, . in. SDR-21 PVC
Company Name 16.INNER CASING OR.TUBING(geothermal closed400p):.. .. •
2.Well Construction Permit#: c�j)t I UVt�V/70 FROM ft TO ft DIAMETER in. THICKNESS MATERIAL
List all applicable HOpermits(i.e.County,State Variance,Injection,etc.)
ft. ft. ill.
3.Well Use(check well use): i7.BCREEN` -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public it, fL in.
OGeothermal(Heating/Cooling Supply) ( sidential Water Supply(single) ft' ft. in'Re
❑lndustrial/Conunercial ❑Residential Water Supply(shared) .16.GROUT..:_.`.:...
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :19.SAND/GRAVEL PACK(if applicable) •
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG:(attach additional sheets if necessary)..
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,Amin size,ete.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Of ft• q ft.
dca
G 2 ,.f ft. Is ft.
4.Date Well(s)Completed:A` Well ID# j
5a.Well Location: nI 5p- ft. as-� �it. t, � ,t
t.
�1 t/?tJ ft. 3W(J iL �t�C
Facility/OwneraS t !(2lt .son ft. ft.Facility ID#(if applicable) ft. f r:^,• i;.Y S'.El:l 1,,f i, 'C`..
/call L o brit Clede ft. ft. SEP 1 8 2023
Physical AdciaRs,City,and Zip -
AV d� 76,6i 733l"737 in OUC4ia r+r-n ,~s4 5 t tiv
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W 6424 �i,1. �o?S=o23
SignaCertified Well Contractor a Date
6.Is(are)the well(s): rmanent or ❑Temporary By signing this form,I hereby certib,that the nell(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 21Qo copy of this record has been provided to the well owner.
If thif is a repair,Jill 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 infection or non-water supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
q
9.Total well depth below land surface: 6J 60 (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: j
10.Static water level below top of casing: di�' (ft.)
Division of Water Rlesources,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 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 May?Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Dlsinfectjiplp type: granular hypocholiite Amount: /NCO+� well construction to the county health department of the county where
constructed.
Form GW4 North Carolina Department of Environment and Natural Resources—Division of Water Resources . Revised August 2013 •
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