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GW1--00346_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 "FR MATERZONEs . DESCRIPTION Well Contractor Name v ft. o2�ft. 1c� 2834-A ft. ft. 1 1 '.S.OUTER CASING(for multi-cased:wells)OR LINER(if an licable).- ' NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL Kennedy Well Drilling 0 ft- Coe-/ ft• 6.25 i in' SDR-21 PVC Company Name r16 INNER,CASING OR TUBING(geothermal closedaoop) �^/�� �r9 /� �( FROM TO DIAMETER THICKNESS MATERIAL. 2.Well Construction Permit#: �Wt2'- (Jo&O//// 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-. --. -. . '=a - Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft. ft in. ❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft' ft. in. 0 Industrial/Commercial ❑Residential Water Supply(shared) f ls.GROUT , FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑hrigation '0 fL 20+ ft• Bentonite Hydrate chips in place Non-Water Supply Well: ❑Monitoring ❑Recovery ft. ft. . Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation .649 SAND/GRAVEL;PACK(if applicable) , y'r':32 FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft ❑Aquifer Test ❑Stormwater Drainage ft. ft. ' ❑Experimental Technology 0 Subsidence Control 20:DRILLING LOG(attach.additionalsheets if necessaryl" ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soirock type,grain size,etc.) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (9 ft• 10 ft• I 10 ft. ft. ,!�-f" ef ir,- 4.Date Well(s)Completed:/0223 Well ID# ® ft. ft. A�� �L 5a.Well Location: 1 LL�� jC� K•e/�k Lee l7F d� 'o ft- ,/ ft• /�.s -�'r..` = i.,„r p° `v, ° / 7 c ,...r a—I. F� .ld..�/ Facility/Owner Name Facility ID#(if applicable) ft. ft. JAN 1 4 2024 I �r 3 /i5 if-31,etoI eV Xd ft. ft. 1 PhyyssiicallAd Ci and Zip .,rt( ,r r.... 1�' ,-. r. ,7, ita ^ 2 00 21:REMARKS^• ' :, County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.eCneetifieaflon:/ N W 8, . ! /a` 023 �� Signature o ertified Well Contractor Date 6.Is(are)the well(s): 5i ermanent or OTemporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or i c 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: 1 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 some construction,you can submit one form. // SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: ?t (ft) 24a. Far 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: / 'O (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6.25 (in.) 24b.For Injection 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: II (ie.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636 Air 24c.For Water Supply&InjectioniWells: 13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of 13b.Disinfection type: granular hypochoirite Amount: 16CIZ well construction to the county health department of the county where constructed. i Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 I