GW1--01013_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Bill Kenned 14:WATER ZONES _
Y y FROM TO DESCRIPTION
Well Contractor Name ft. ft
2834-A ft. ft. i ,
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased wells),OR LINER(if ap Ikable)`
FROM TO DIAMETER THICKNESS ➢ATERIAL
Kennedy Well Drilling 0 ft- afi ft 6.25 1 in. , 1 ( /v.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
,.. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 00
07 — 00� ,..5 d D ft 35— ft. a/1, in. SCt- �(/ ci
List all applicable well permits(i.e.County,State, a lance,Injection,etc.)
ft ft. 1 in.
3.Well Use(check well use): 17.SCREEN ' ,
Water Supply Well: - .- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mjcipal/Public
❑Geothermal(Heating/Cooling Supply) 06sidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLAC METHOD&AMOUNT'
❑ GO ft (�ft poi ItO u
Non-WateWate r Supply Well: �"' G ��Py'�
❑Monitoring ❑Recovery •
ft it.
Injection Well: ft ft.
OAquifer Recharge ❑Groundwater Remediation 119.SAND/GRAVEL PACK-(if applicable) - - '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft '
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -" - E- " --
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,solllrock type,grain size,etc.)-
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft. 'i -.-.
�1
f ft. ft j
4.Date Wells)Completed:L// �6-0 warm •i?a ins ! R ft - 1- -
5a.Well Location: l 1/ _Z ft. ft. �l I `� ,tli;
_i
I-rad/ 5 t1la/t 14- ft. ft. X`.
Facility/Owner Name Facility EN(if applicable) FEB B 0 II, 20 Z'4
�.J r /� ft. ft.
(,t` ! a. / 2n 4 k f`'� L ✓(L ft ft. -7I
Physical Addres,City,and Zip tiljt.i1f16::tF�'1 r "'r iy V141f
�t ��� 74/ 5-3-02a/ „al-- ss�e% 3s /,• n � . v
County Parcel Identification No.(PIN) I '
I.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/lang is sufficient)
N W 13., y// • 1— /I`�
� Signature ertiried Well Contractor' Date
Perm 6.IS(are)the well(s): Hanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: es or ONo 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 diagrain 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: ' ✓"/A- construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ON Ywith the same construction,you can
submit one fonn. 2 P SUBMITTAL INSTUCTIONS i
3$
9.Total well depth below land surface: / (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: r-)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
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: t,
(ie.auger,rotary,cable,direct push,etc.) I i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall ServiceiC nter,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
granular hypocholrite well construction to the countyhealth department of the countywhere
13b:Disinfection type: Amount: 00z_ • ep
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-D. R'esr Revised A"