GW1--01018_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:
14 WATER ZONES. i:-.
Billy Kennedy FROM TO DESCRIPTION
• Well Contractor Name j S0 ft. l i�f t' a�!p'ebt .
•
•
2834-A fL 8'
NC Well Contractor Certification Number S OUTERCASING,"(for molt ie s).OR LINER.(1f applicable).
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 fr. az ft. 6.25 4 SDR-21 PVC
Company Name
„16i INNER CAS G OR>TUBING(peotheimalilosed-loop): ,
�^r� �[2 FROM TO DIAMETER THICKNESS MA'[EERIALL
2.Well Construction Permit#: t�3z[s'3 —C��TJ, 0 J ff tit s ; in. e-lt W ff,,''//JJ
List all applicable well permits(Le.County,State,Variance,Injection,etc.) / VG
ft. ft. in.
3.Wei Use(check well use): 17 SCREEN .";5
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici lic ft. ft. is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R in.
ROUT '' •:
0 Industrial/Commercial ❑Residential Water Supply(shared)
i1SFR[OGM TO MATERIAL EMPLACEMENT hfETHOD&AhiOL'NT
❑Irrigation 0 ft 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well: •
OMonitoring ❑Recovery 0 ft. 00 ft. p' Akt "par
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .<19.SAND/GRAVEUPACK Of epplicabie). ,
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage - -
ft. ft.
❑Experimental Technology ❑Subsidence Control r^'.
20 DRILLING;LOG.(attsclt additional-Sheets if necessary'e E.... ._.,G.,. j J2"'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soWio �,i )1r.•
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. / f t. 7 p �1/ I FF B e e 2024
4.Date Well(s)Completed:I-8-ay Well ID# Jo
'ft 420 ft. 46/UUUIII n‘ 44C n " �.. .11 U11/ I
5a.Well Location: /� /� . �/ it 0
of 1 E1 tilti,51, ;r1,-1-1-45.1 ft. ft.
Facility/Owner Name ✓ Faciiity ID#(if applicable)
117 'rOL/,t �r�.,e &-1t.u,'&h I`� fL ft /3 �'a �
Physical Address, ity,and Zip
31'' rU ,,
le
County / Parcel Identification No.(PIN) We. rem aL^ p� i c- //. "1O f f '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification• [ b (/OG
(if well field,one lat/long is sufficient) /
I.
N W ' ����
Ai
Signature o iertifi Well Contractor' Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
,� with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: IGYes 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 die
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: I 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: Q.149 (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: ' ifv (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY::In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following: ; •
(ie.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /J 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 ttypocholrite Amount 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