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.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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