GW1--01700_Well Construction - GW1_20240315

I I
WELL CONSTRUCTION RECORD ' For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: I'
Bill Kennedy .14:WATER ZONES ;., . .. ..-
Y FROM TO DESCRIPTION
Well Contractor Name Si) ft. raft. ycl
iwo id,
2834-A Ja2ft. /30 ft. oZ il�
NC Well Contractor Certification Number 15.OUTER CASING(for:multi•cas ells)ORi'li LINER(if'ap livable)
FROM TO DIAMETER II THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. S9, ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING,(geothermal closed-loop).:.
n� /�,� �1 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#:120 I q `Cif oo c!X ft. ft. to
List all applicable well permits(i.e.County,S ate,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use): '17.SCREEN . '` `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) �R s dential Water Supply(single) ft ft in.
❑lndustriallCommercial ❑Residential Water Supply(shared) IS GROUT
FROM TO MATERIAL h EMPLACEMENT METHOD&AMOUNT'..
❑Irrigation 0 ft. 20+ ft• Bentonitel Hydrate chips in place
Non-Water Supply Well:
•
❑Monitoring ❑Recovery ft ft. i
Injection Well: ft. ft
DAquifer Recharge 0 Groundwater Remediation -'19.SAND/GRAVEL PACK(if applicable)'' .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEbfENTEfETHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) - OTracer FROM TO D ON(color,hardness,soWrocktype,grain size,etc.)
0 Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft• 30 ft• P rfr
a'`a�4, 30 ft. 6'0 ft. 6rc2 ns1�ni° t-• 1a - dick
4.Date Well(s)Completed: ell ID# �
5a.Well Location: � ft. n 2 ft. /1 �O /o
ft. �CO�� ft. C7 v�
i.- .n
a(Le- L /j Y)V e d' ft. ft. 1 1 i-:-ti-: �. it.`y ;y, .
Facility/Owner Name Facility ID#(if applicable) t '--, • k� L4)
]-6A Tot !7[ I-0 r r►-r / ft
ft. ft.
ft. I Mhos? 1 5 2024
Physical Addres City,and Zip 21.REMARKS iftii,.ate, T 3..---..„•.
Al o*4
Dtoicu
County Parcel Identification No.(PIN) I
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I
(if well field,one lat/long is sufficient) ' I
N W r a _&-aL,� Signature edified Well Contractor Date
6.Is(are)the well(s): 8I'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�- with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [31Vo 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 tti 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
r�
9.Total well depth below land surface: t3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following: i I,
10.Static water level below top of casing: 26 (ft) Division of Water Resouirces,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:I II
addition to sending the form to the address in
24a above, also submit a copy of is form within 30 days of completion of well
12.Well construction method: rotary construction to the following: I '
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce ter,Raleigh,NC 27699-1636
13a.Yield(gpm) .3 Method of test:.Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this ford within 30 days of completion of
granular hypocholrite 13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Ii
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013