GW1--01702_Well Construction - GW1_20240315

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be wed for single or multiple wells
1.Well Contractor Information: !1
14-WATERZONES 4I3} .._-`
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name t:Gt.c ft 70 ft q I I
2834-A ft. ft. (/
NC Well Contractor Certification Number 15 OUTER CASING_(fur multi-cased wells)ORLINER`(If ap licable): „ ...
FROM TO DIAMETER I, THICKNESS MATERIAL
Kennedy Well Drilling ft ya it 6.25 jli;'• SDR-21 PVC
.JN Company Name -16NER CASING OR TUBING(gcotheri6al closed-loop)':. _.
/� �� FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: C ll it. ft. r//1 iu. - O j,)fir
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) V '7 Y(�
ft. ft i m.
3.Well Use(check well use): 17.SCRE);N ;:
Water Supply Well: FROM TO DIAMETER ',SLOT SIZE THICKNESS MATERIAL _
DAgricultural ❑Mu��nicipal/Public ft. ft. In'
❑Geothermal.(Heating/Cooling Supply) C2'Residential Water Supply(single) ft' ft. 1° I
_.-
❑IndusttiaU •18'GROUT ,, .
Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft• Bentonite I Hydrate chips in place
Non-Water Supply Well: ,J �/ 1
❑Monitoring ❑Recovery D f t. S 3 ft• per T l .,l�e p el enfi pea—
Injection Well: ft ft.
it
❑Aquifer Recharge ❑Groundwater Remediation 19?SAND/GRAVEL;PACK(if applicable)' i-9,1':f
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier I ft. ft '
❑Aquifer Test ❑Stormwater Drainage ft. ft. I,
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG,(attach additionalsheetsif necessary')":-'' ...:
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.sotl/rock type,grain size,etc.)�..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft• ft. /
a
ft a6, ft.
4.Date Well(s)Completed: TP ell ID# / ,,�✓ �,d � ��_.. ^., ,
'' f t Q7LC7 B C' r i,'4"°.'(,,., R . i ?�.. ' •
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5a.Well Location: ft- ft. i
/b �. J I./ MAN 1 I-'
"�LJ I r l'I✓�! �rJ/l�i�'"1 fW ft. ft i� i t e, �U24
Facilitlhvner Name Facility ID#(if applicable) ft. ft. " oil ;,;y,� P .�
• s l + ':.;fir*�tJ,J /� 7'
'7 �� �Q C7/ r 7 rt it tt. CeiNec xt�
PhysicaJan
s,City, Zip 21'REMARKS
/ k 9 ,5"-q TA lif S,3 ' Ir,/t e/ s ea�, /U ri
County Parcel Identification No.(PIN) a 3-7_to ii
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W `-� ®1✓' c - a 4Li
— Signadnr Certified Well Contractr71 Date
6.Is(are)the well(s): 13Permanent or ❑Temporary By signing this form,I hereby cert jy 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: 24 or 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 ;' 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 for 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: 0(1,(5 (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:
1.
10.Static water level below top of casing: O�oZ (g) Division of Water Resou ices,Information Processing Unit,
If water level is above casing,use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
rota 24a 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) 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 hypocholrite Amount: ©DZ.- 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