GW1--00347_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:
°,14:WATER ZONES `- 1i
Billy Kennedy FROM TO DESCRIPTION . .:
Well Contractor Name >�ft. /6-Ch
. `4' IrK
2834-A ft. ft. i
1S.OUTER CASING(for multi-eased.wells)OR LINER(if ap llsiable)
NC Well Contractor Certification Number
FROM TO DIAMETER ' THICKNESS MATERIAL
Kennedy Well Drilling 6 it. `i e n• 6.25 ' in. SDR-21 PVC
Company Name -16,'=INNERCASING OR TUBING(geothermalclosed l(np)*` r` .,
FROM _ TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft:: (JCOot l.�? ' 00006$HO) ft. ft. ' m•
List all applicable well permits(Le.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) esidential Water Supply(single) ft. ft. in.
8:.
❑IndustriaU 1
COmmercial ❑Residential Water Supply(shared) FROMGROUT TO f MATERIAL ENLACEMENT 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 ,'19r SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Exptximental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary).''''
r„ <,e.s,..,.,�
❑Geothermal(Closed Loop) OTracer FROM TO DESCRH'T ON(color,hardness,soWrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. ft. D a.
``�-�22 ft. z/O ft. A```��%%���.. �&i etc.
4.Date Well(s)Completed: ��`(� �R'ell ID# ft. /W ft. 6�_�l�1:/`'.k
5a.Well Location: ft. 7��/ ft. 'FX r.. ^, r. r':' , -"'t
v it r i e- 1-'.0 ft. ft. I, 1+.t;... L..1r. k9 a,...2.../
Facility/Owner Name p Facility ID#(if applicable) ft. ft. J A N 4 2024
1702C7 o'J�X /-.ems i° -riii /' ft. ft.
Physical Address,City,and Zip in-, 'i. r
'21.REMA ics '„ .ft)wcinu.vit r r ry
4�/o/4l, 7749q(937/ r . d.3
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one lat/long is sufficient)
N W 6L1// ` /a- eo, --093
Signs .46 Certified Well Contractor Date
6.Is(are)the well(s): • ermanent or OTemporary By signing this form,I hereby cernfy that the well(s)was(were)constructed in accordance
with 1SANCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 81Vo 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 iron-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: !Q® (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(1200'and 2(0100) construction to the following: f
10.Static water level below top of casing: t -e2 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,
ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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:
(ie.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) 7 Method of test: Air 24c.For Water Supply&Injectionli
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: /�d
constructed.
Y
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013