GW1--01699_Well Construction - GW1_20240315

I
WELL CONSTRUCTION RECORD For Internal Use ONLY: !I
This form can be used for single or multiple wells I
1.Well Contractor Information: ,
.14.WATER ZONES ',a"t ti '' - .,
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name 4,10 ft. 6'1 ft. 6,, 1
2834-A ft. ft.
NC Well Contractor Certification Number '15::OUTER CASING(for-`multi-cased'wells)OR LINER(if Op licable)
FROM TO DIAMETER,' THICKNESS MATERIAL
Kennedy Well Drilling co ft. 017 ft. 6.25 , lin• SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING( eothcrrnal closed400p)-,'. .
• FROM TO DIAMETER' THICKNESS MATERIAL _
2.Well Construction Permit#: ®�� 'a ��7 ft. ft. is •
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. , in.
3.Well Use(check well use): 17..SCREEN Y
Water Supply Well: FROM TO DIAMETER' I SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Music' allPublic it, it in.;
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) R f C�'Re in.: l
.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) 1$FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irigation 0 ft' 20+ It. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: • ft. ft. I
❑Aquifer Recharge ❑Groundwater Remediation 49.SAND/GRAVEL PACK(if applicable)' : .' lr., ",•
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft. is I
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soirocktype,grain she,etc.)
Ev ft. -, /� 1
0 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0ft. 7I C.-/
��1l �[ ft ft. 1r_ / /J _r.k
4.Date Well(s)Completed:tX— ��a T Well ID# s--ft 1 93 ft. � i /�„®/_ /�
5a.Well Location: /�' ft. otCx,�ft. ��h
Al i r' ft. ft. l E .6,.....e ►1
Facility/Owr Name Facility ID#(if applicable)
ft. ft „.
MAR •
3Li/ �_ r ft. ft. �c 2024
Physical Ad s,City,and Zi y ^� 'J /^ �/ 21.REMARKS,'"s ; k "itl`� " n1?
County /` Parcel Identification No.(PIN)
I:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i•
(if well field,one'at/long is sufficient) ;'
___/ N i W uh�q /a�' a—9 r a 4i
Sigma Certified Well Contractor: 1 Date
6.Is(are)the well(s): Glilrmanent or ❑Temporary By signing this form,I hereby certify thkt 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 l o� 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 Ito 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: d1/403 (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: 30 (ft.) Division of Water Reslitirces,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
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resourcesj Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test:
Air 24c.For Water Supply Be Injection Wells:
Also submit one copy of this f'omi within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: well construction to the county health department of the county where
e.- constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013