GW1--07635_Well Construction - GW1_20231204

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WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells i
1.Well Contractor Information:
14:WATERZONES is :
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name i>�JfL /�D' {
2834-A I eJ t J�7J f` ' i ' ,34
NCWe1lContractorCertificationNpmber IS UTER':CASING.(forriruiti ase,'y�My llll"syOIdLINER(if:ap-lieable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft' 1/0 re' 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#: =~ keiy ft. ft. in. .
List all applicable well permits(i.e.County,State,Varian e,Injection,etc.)
ft. rt. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. it. ft. in
[Agricultural - OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well: -
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation ''19 SAND/GRAVEL PACK if applicable) ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEhrENThrETHOD
❑Aquifer Test ❑Stomrwater Drainage ft, ft.
❑Experimental Technology 0 Subsidence Control :20.DRILLING:LOG`(attach-additional;sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/reek type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft, 5' ft. �q'
v-
4.Date Well(s)Completed:/L'` y "23Well ID# ?�tt. 05'ft. � ; roe,i�
o ft. ft,
5a.Well Location: ft. 2
` ,75.0 7e e S ft. ft. z i�. F. _•i r'. _T�
Facility/owner Name Facility ID#(if applicable) r•
�'�' !� o r �''�v'n ,��,(f c�� it. ft. DEC, t) / ZUL3
Physical AddresiCity,and Zip y
el - 21 RFJI4IARK5;" -. :...,.,.
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) �
N W _ / /D-23 013
Signs - 1 Certified Well Contractor Date
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6.Is(are)the well(s): Rilrmanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Ines or �1Vo 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: l 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: " (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�, mand 2@100') construction to the following: !
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10.Static water level below top of casing: iffl (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 Cm.) 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 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tJ® Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this'form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: 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
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