GW1--00348_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 FROM
WATERZONES .__ =a�
FR TO DESCRIPTION
Well Contractor Name a7Oft• ago&
2834-A ft. ft. a✓�
15.OUTER CASING(for-multi-cased Wells)OR
NC Well Contractor Certification NumberLINER(if ap![cable)''.
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft 7® ft 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) . ,,, _.
^��02f�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: c)3 ft. ft. in. _
List all applicable well permits(i.e.County,State,Variance,I+jectton,etc.)
ft. ft. in.
3.Well Use(check well use): 37,SCREEN ,'
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.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '
FROM TO MATERIAL` EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft" 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. /CD bads,
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19'SAND/GRAVEL PACK(if applicable) .:::-� _ - - -•_••'"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it. ft. 1,
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
❑Experimental Technology 0 Subsidence Control 1
.20.DRILLING LOG(attach additional-sheets if necessary),. , : ,` '.'';;.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft' ' ft. et t
/a'7a3 ft. 6o ft A�� ."
4.Date Well(s)Completed: Well 1D#
(O
5a.Well Location: It. 20 ft- 6-J/fdG�
t/0c 8-Loh Qh r°.4" ft. ft. Z-" ,...,f,y,; ay, 4 D
FacilitYOwneer Name J Facility ID#(if applicable) ft. ft. JAN V 1 2024
a6o z-/ Lia-P f 0 F\ ft. ft.
r
Physical Address,City,and i •ZfrRE1vIAR1{5 s, .``' �.'' .:•; � t 4 `. . 24••�„�
, ct i0/10I. inirr,L'��tn 'fir is '77`//7)3/ 76
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
N W 45. `� - 1a -7-4S
Signature ertified Well Contractor Date
6.Is(are)the well(s): et
El manent or OTemporary By signing this form,I hereby certrfy that the well(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Etlq copy of this record has been provided to the well owner.
If this is a repair,frll 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
,ie7 9.Total well depth below land surface: r�f 7 (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:
10.Static water level below top of casing: Ve, (ft.) Division of Water Resources,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 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 Ce'nter,Raleigh,NC 27699-1636
13a.Yield(gpm) a__ 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 type: granular hypocholrite Amount: 1�p� well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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