GW1--07745_Well Construction - GW1_20231204

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: I
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATER ZONES ' i; ' - .
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name r{' ft Ce-0
ft.
2834-A log-rt. //0 it. SN PVI
NC Well Contractor Certification Number 15.OUTER CASING(for multi wells)OR LINER(if ap hcable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. i/a it• 6.25 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop):
a /t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Ot2.3 "07 yt0 ft. ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
• ❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) ft. ft. in.
18.GROUT -
❑lndustrial/Commercial ❑Residential Water Supply(shared) 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 ❑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.
1.
❑Experimental Technology 0 Subsidence Control
20.DRILLING 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)^�'P ❑Other(explain under#21 Remarks) 6, ft.
ft. & ft. /� V, ao pt k
4.Date Walls)Completed: i'i�otJ Well ID# it 3� ft nI_feA1`"""le e `k
() P �l 3.�ft. a a c-fr. /j /r k. ISO
5a.Well Location: l� I rt. ft. �(� _ _ _ _ - _,
r.
leite,I-®;i r /3c)5 We-/I ft. ft. I!''s.;��,.%`i&.,_,.ii`ki 1,..-... M1
Facility/Owner Name ' Facility ID#(if applicable) it ft.
35`Y Fronk I,'nJl•/% .cf n-, - 2(19�
rt. rt.
Physical Address,City,and Zip 21.REMARKS ` 1,..=r- i? , '''Y ',..
Ac,.Ja/ps 67 3 £N1/6 62q r,,> ,
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W . .4l I���r.4 //4 =a3
.� Signature o died Well Contractor Date
6.Is(are)the well(s): El ermanent or OTemporary By signing this form,I hereby certify;that the well(s)was(were)constructed in accordance
/ with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I�PO copy of this record has been provided io the well owner.
If this is a repair,fill out known well construction information and explain the nature of the j
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. ^,✓ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �CaCS (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: 1,
10.Static water level below top of casing: 0 (ft.) Division of Water Ri sources,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 Injection Wells ONLY:,In addition to sending the form to the address in
rota 24a above, also submit a copy id 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite well construction to the county'health department of the county where
13b.Disinfection type: Amount: /Oa<
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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