GW1--07737_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 ,
1.Well Contractor Information: ,
14.WATER ZONES:.. . I :I. •
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name et' q0 ft' gpi,4'1 d-'/(E,o I•/j p s
2834-A . . 8'f` co ft c,,&I d-- 305 % 3600 -to�,4,
NC Well Contractor Certification Number 15.OI)TERiCASING(for.m sed hells)OR LINER(If a .licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 30 it 6.25 I; 'ln• SDR-21 PVC
Company Name `16.INNER CASING OR.TUBING(geothermal closed-loop).: .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. ft. in.
List all applicable well permits(Le.County, tale,Variance,Injection,etc.)
ft. ft. hi.
3.Well Use(check well use): 17.SCREEN -
Wale apply Well: FROM TO DIAMETER SLOT SILO THICKNESS MATERIAL
cultural ❑Municipal/Public It. it in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT: :-.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation • 0 ft' 20+ ft. Bentonite Hydrate chips in place /oZ ben s
Non-Water Supply Well: •J ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation '19.SAND/GRAVELPACK(if applicable)
-FROM TO MATERIAL EMPLACEMENT METHOD
'1- ❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. it
ch) ❑Experimental Technology . ❑Subsidence Control 30.,DRILLING:LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO D ON ty,olor,hardness soil/rock type.grain sire etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. fill R. a
4.Date Well(s)Completed:/[ "/`�3 Well Ill# /U it a I f t AFn l n
�y ft. /2(0S-ft. /,I o
5a.Well Location: r ft. 66�v ft. /.7,:
loll !Ou! Jim L'Lc- ft. ft.
Facility/0 er Name Facility ID#(if applicable) a •• ;
ft. ft. e i,
f(2&fs tipper / -'
t0 rt it. n rr
Physical Address,City,add Zip '-"7 ,'• 7 ,
�ry� 21c REhIARKS' .... . .. . . Z�2�.
• r,)d'r�- r'/I/0/O?'a 0 • in; ?_:.,ri
County Parcel Identification No.(PIN) DINT-... :.•:, '•::.) U;:6
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/lang is sufficient) /
N W Signature/ � ertified Well Contractor /L 7-a3
6.Is(are)the well(s): t manent or OTemporary By signing this form,I hereby ce#ify;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 25 o copy of this record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and explain the nature of the
repair wider#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: I 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. 9 SUBMITTAL INSTUCTIONS:
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9.Total well depth below land surface: -�Lt/25 (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 2Q100) construction to the following: '
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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: ry construction to the following:
(Le.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
!/ L•� Air 24c.For Water Supply&Injection Wells:
(gpm)Yield 0. Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: f(yA� well construction to the county health department of the county where
constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013