GW1--07733_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FFROWATER TO .t ..DESCRIPTION
Well Contractor Name lid ft. (I5- ft- a
2834-A Iffy f` ' / f• `.5 •
NC Well Contractor Certification Number 'a15 OUTKR CASING{for multitFS IN welts)OR LER(if op Ileable).,
FROM T` DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0ft- , ft- 6.25 in, SDR-21 PVC '
Company Name '`16.'INNERCASING-OR TUBING(geothermal closed-loop) :
��// FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: `4703 h ft. r/ in
Listallapplicable welipermiu.(In County,State,Variance,Injection,etc.). •
Y ft �CA,-!® �
ft. ' ft. ' in. ,
3.Well Use(check well use):
',,19sSCREEN _
Water apply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural ❑Municipal/Public it ft in
gn
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18z cROirr
FROM TO} MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it:-20+ it' Bentonite Hydrate chips in place
Non-Water Supply Well: s,�
❑Monitoring ❑Recovery t% R' (€n ft. 4t`fi€ stet ille-t GPkstAlr°tt , ,ICr
Injection Well: ft. ft.
['Aquifer Recharge ❑Groundwater Remediation `19 SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD -:
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage .: ft. ft,
❑Experimental Technology ❑Subsidence Control
,20rDRILLING LOG(attach additional sheets if necessary) ,,c ' ';`, ,,
❑Geotheal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soArock type,grain she,eta)"
ml
ft.C/
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D it' IJ r'„ -
4.Date Well(s)Completed: [X 7-oll ID# � fi aQ ft '6'�On �
5a Well Location: a.o f t. 3 f• &"` aGk-
ft. ft
Long hat, 1 f u"in U C- ft. ft.
Facility/Or Name Facility ID#(if applicable)
__v ft. ft. (1Cr ^� ^
l (2? (if 0 t� y e /�Ci1 fL ft. - _ t_r L
Physical Address,City,and flip 21 REMARKS ;-; _tp. , t t:i.:;
County Parcel Identification No.(PIN) ` , ,� / `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiifrcation:
(if well field,one lat/long is sufficient)
N W g- 09'- a3
Sigma f Certified Well Contrac Date
6,It(a[e),theweU(s) G?Petrtttanent. or ➢7Teingorary
Byslgninng this-form;I•hereby certify that-tie•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: [Wes or 21(o 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. 2 ,ram SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: oL57 (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: /0 (g,) Division of Water Resources,Information Processing Unit,
If water level is above casing use"4." 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
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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) CIO Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fora within 30 days of completion of
granular hypocholrite well construction to the countydepartment liealth of the county where
13b.Disinfection type: Amount: ,fo2 t9a
• •constructed. 1
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013