GW1--01016_Well Construction - GW1_20240209

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells
1.Well Contractor Information: 1
Bill Kennedy 14:WATER ZONES , i;:F .
y Y FROM TO DESCRIPTION
Well Contractor Name SO ft' ,5- —ft 3 I''
ft. ft.
2834-AJ�1
l I
NC Well Contractor Certification Number
1Sr;OUTER'CASING(for multi.casedwelis)OR'LINER(ifap lIcable) :
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a it. 30 ft. 6.25 j in. SDR-21 PVC
Company Name ,16INNER':CASING:ORTUBING'(geothermal:closed400p) _ -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: dE/a.3-02 0 8.1 ft. ft. ' in. .
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft.
3.Well Use(check well use): 17iSCREE[V.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu��nicipal/Public ft- ft in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
<11k GROUT `=:_
❑Industrial/Commercial ❑Residential Water Supply(shared) •�' .' •-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation -
Non-Water Supply Well: f`' 20+ ft• Bentonite Hydrate chips in place
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation `19:.SAND/GRAVF.I PAC$(if applicable),
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft I
❑Aquifer Test ❑Stormwater Drainage
ft f. !
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG:(attach additional sheets if neeessaryj
❑Geothermal(Closed Loop) ❑Tracer FROM TO - DES 'I r.w N(color,hardness,soiltrock type,grain size,etc.)
- ❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft. T. ft. /1 e•I }A c, Ie. A !/to
4.Date Well(s)Completed:,/& a4Well ID# it ft �t J �
'-1 P� ft. ^� ft. `Qe�if ry
Saa.Well Location: / d[V ft. ✓ tt f e s,a% �
1`^l J et �.P9 O r ft. ft k Z.E'L,./(,�i V . 1.;
Facility/Owner Name Facility ID#(if applicable)
�3� /ul? ` 7' Zvi%/1 /Y,P ft. ft. F-B p 2fi74
ft ft
pPhysical Add City,and Z
;21REMARKS:: .. i}fG'![ .tfSl.0,•f
"ki9i?y ii
G� t� `i R60776.L 2)E/
l�1tr'Lil��
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)
!
4"4.-**' /—/6'- °ti
Signature eni ed Well Contractor Date
6.Is(are)the wlll(s): ermanent or DTemporary By signing this form,1 hereby certify;that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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 I
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,
9.Total well depth below land surface: 303 (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: (D) 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 (n.) 24b.For Infection Wells ONLY: !In addition to sending the form to the address in
rotary
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.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) 3 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: granularhypocholrite Amount: iUjO 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