GW1--00310_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name gr ft' 8`,j I y w.,...,.
2834-A i p ft /9a ft. 6, sed'sle1C
NC Well Contractor Certification Number 1 .OUTER CASING(for multFca )OR LINER(If cable)
KennedyWell DrillingFROM � /� DIAMETER to THICKNESS-2MATERIAL
6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 'a gt7 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 SLOT SIZE THICKNESS MATERIAL
[Agricultural ❑M pal/Public ft. [t in.
❑Geothermal(Heating/Cooling Supply) Of sidential Water Supply(single) B ft. n
❑Industrial/Commercial ❑Residential Water Supply(shared) 1$.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ R Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
�p �SOMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
LJGeothermai(Closed Loop) ❑Tracer FROM TO DES ON(color,badness,soft/rock type.pain size,etc.)
❑Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) © ft S- ft• f t„t--
3^
4.Date Well(s) //Completed: � `,` Well II)# 'S ft.
t -7� ft �� ��e _`S�/c
5a W cation: 30 it 0705 ft. Ae. ,c9c-i_
�/ //S ft. ft.
�8�/t ft. ft.
owl ;� 'T _Facility/ r Namem �j Facility ID#(if applicable) ft. ft. -•f 5
FD
/2 I La if/t!/i i jCJYi A ft. ft. `1 '1".-1 i
Physical Address,City.and Zip J 21.REMARKS J 1 2024
rz1�Ira.-►1 kS c� ln;c,-�t(.,ll4 VI Pr^
County Parcel Identification No.(PIN) OWC4e,SOG
4b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /
N W �!-
// Signature Certified Well Contractor Date
6.Is(are)the well(s): t�Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IGNo 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c .ta5 (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(0,100') 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 Marl 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
rotary 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.)
f>ivlsion of Water Resources,Underground Injection Control Fromm,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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 granularhypochohite Amount: It,-�1 well construction to the county health department of the county where
type:
constructed.
Form(P,Y-? North Carolina I apartment of Environm_t.and Natural Resources-Dt,t.;ioa_of Water Resources Revised Aeigsat Ta)?