GW1--01021_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: I
BillyKennedy14WATERZONES
FROM TO _ DESCRIPTION
Well Contractor Name 60 ft. �+© ft. s—=®
2834-A Is-0 ft. iJs 5-tt• JJi Jew
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cis ells)ORLINER(if ap licible) '`
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling e ft. y7.ft. 6.251 in, SDR-21 PVC
Company Name 16 INNER CASING OR TUBING(geothermal closed-loop) . '
������� FROM TO DIAMETER THICKNESS MATERIAL `
2.Well Construction Permit#: t f`�23 ©[,i V3 L9O ft. ft. I . in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. ft.
3.Well Use(check well use): 17.!SCREEN' •.'r
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
18.GROUT
❑Industria]/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 ft' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. . ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable) ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERiAI EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage it
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) ,:
❑Geothermal(Closed Loop) OTracer FROM TO D TION(color,hardness,soilrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. S� ft. ;F.*.
4.Date Well(s)Completed:j—L5 Y ell ID# ft �/� tt 11,0e2,0
�yy11 ��Q ��r��,t
5a.Well Location: _ ,`„ ft. �_!�Z r• If�G f o y
ZOO �t �[/ �/ f ,, °e ..r
,t�u �s_ ft ft.
FacrilitrFacility/OwnerNam
j /� Facility ID#(if applicable) ft. ft. FEB 0 2074
// &3 eleii/( Ci ''y I ft. ft. '
Physical Address,City,and Zip 21.REMARKS:,'. ,. ` :a,.Dy1 5Q(.- . , .
t0//4� 7.7006 ...
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) L,
N W 64ii <.ejSignatrtified Well Contractor ate
6.Is(are)the well(s): O1'ermanent or ❑Temporary By signing this form,I hereby certify 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 IMPo 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 non-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS 1'
�+ a
9.Total well depth below land surface: !6' i
V (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100) construction to the following:
�L� I
10.Static water level below top of casing: 3-5 (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 Infection Wells ONLY:1 In addition to sending the form to the address in
rotary24a above, also submit a copy bf'this form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) 1 '
Division of Water Resources,.Underground Injection Control Program,
FOR WATER SUPPLY
WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O(s7 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 hypocholtite Amount f P� well construction to the county jhealth department of the county where
constructed. ,
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August2013
I
i