GW1--06301_Well Construction - GW1_20230926

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
f ,
BillyKennedy :14WATERZONEs . f.
FROM TO DESCRIPTION
Well Contractor Name +90 it Cga ft ,Cj is -.
2834-A `/ ft. ft. ✓jII
NC Well Contractor Certification Number 15.'OUTER CASING(for multi=case'd wells)OR LINER(if ap licable)'`
FROM TO DIAMETER• THICKNESS MATERIAL
Kennedy Well Drilling 0 ft 3 el ft• 6.25 ! in• SDR-21 PVC
16.INNER CASING OR TUBING "
Company Name (geothermal closed-loop)
7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ©� 0a0O/h/ 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 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft it in.!
0 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft' ft. in.`
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18i GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ID Irrigation 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 ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT➢fETHOD
it. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20:DRI LLING'LOG'(attach additional sheets if necessary) ..
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) a ❑Other(explain under#21 Remarks) a ft ^^E� ft. dace,
fete
4.Date Well(s)Com leted:7 o3 Well ID# ft tQQ f L '"��- "
P ! ao ft. as. ft. Ralik
5a.Well Location:�` ^ ' ' 305' A� tft„O
�Gk�t-` &&cei ie- ®co ft. ft. Y�
Facility/Ownerne Namt J Facility ID#(if applicable) r.�
�3 Z� a- A flay
�) �+ ft. f t. r"''' r 7 q`°°(,.- R ik J tt�F)
CO. /.fl(/ �9`7 ft. ft. 1 5 -6 L...'4= P S"' i. k
Physical Addre ,City,and Zip I
Aa l 1 76,3 5'71o8C - SEP 2;
•, 023
d �,.
County . Parcel Identification No.(PIN) of �ti.+:+:'3�I
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: G 'i`°1"`"
(if well field,one lat/long is sufficient) 22.Certification: Q
N W A ' ! _ 43
Signature o "itize,i,v14,
Well Contract Date
6.Is(are)the well(s): ermanent or ❑Temporary '
By signing this form,I hereby cerl fy.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 21Vtt 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:
S.Number of wells constructed: / You may use the back of this page Ito provide additional well site details or well
construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can I
submit one form. ✓ SUBMITTAL INSTUCTIONS I .
9.Total well depth below land surface: ,gas (ft) 24a. For All Wells: Submit thisl form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200and 2@100) construction to the following:
10.Static water level below top of casing: ..O (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 Infection 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: 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Air 24c.For Water Supply&Injection Wells: ,
3 Method of test: ,
0 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: ! r� well construction to the county health department of the county where
_ _ constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013