GW1--01710_Well Construction - GW1_20240315

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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' 1.Well Contractor Information: I
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Billy Kennedy •14:WATER"zoNES :>: , _l -
FROM TO DESCRIPTIONII
Ft ; Well Contractor Name.",- 102U ft /5 9t 3yio
2834-A '' ft. ft. I
NC Well Contractor Certification Number 'ill.OUTER CASING(for multi-cased wells)OR LINER(if op'licable) ' .t
FROM TO DIAMETER I I' THICKNESS MATERIAL
Kennedy Well Drilling D ft aril' 6.25 iinir , SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).. ,
/ �� FROM TO DIAMETER I' I THICKNESS MATERIAL
2.Well Construction Permit#: 4 ft. ft.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. It.
3.Well Use(check well use): 17.:SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in. I'
❑Geothermal(Heating/Cooling Supply) reside��ntial Water Supply(single) ft. ft' in I. I
❑industrial/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:
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation ,19.SAND/GRAVEL PACK(if applicable) "
[7Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL' I EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stonmwater Drainage ft ft. i 1
❑Experimental Technology ❑Subsidence Control '20.DRILLING LOG;(attach addllionalslieets if necessaryy)`'°' W :
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft• 3 ft. r rt-1
4.Date Well(s)Completed:a- `�gWell ID# //r 3ft JS'ft 2�jfp�� ��,ye'
5a.Well Location: !J it ay3c, ed/7 t
/I yci A 4QsS ft ft. A� 1 IZ „1
Facility/OwnerName Facility ID#(if applicable) ft. ft. MAR 1 � ',0Z4
1-6 0 if te)Y as ft. ft. I' tn,urar,r ;r,n P ^;%,
Physical Address,City,and Zip 21:REMARKS • `'_• - ". `- z Dleik;s o t'. %/Mi`'`
jitroi e- DODO 0 a 7 - - .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
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N W a—s=cad
� Signature Certified ell Contractor Date
6.Is(are)the well(s): I manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISANCAC•04C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DA r� 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 l' 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 to provide additi
8.Number of wells constructed: ! onal well site details or well
constmction details. You may also attach additional pages if necessary.
For multiple it jection or non-water supply wells ONLY with the same construction,you can
submit one form. / SUBMITTAL INSTUCTIONS i.
9.Total well depth below land surface: t-`'73 (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: Ij
10.Static water level below top of casing: 70 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cnter,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in) 24b.For Injection Wells ONLY: ln 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 1,
(Le.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
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? Method of test: Air 24c.For Water Supply&Injectiou
13a.Yield(gpm) l Wells:
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Also submit one copy of this form within 30 days of completion of
granular hypocholrite Ja well construction to the county health department of the county where
13b.Disinfection type: Amount: I I
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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