GW1--01725_Well Construction - GW1_20240315

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells i
1.Well Contractor Information:
14.WATER ZONES l 1 . `
Billy Kennedy •
FROM TO DESCRIPTION
Well Contractor Name 1J,TL -0" 1 1
2834-A a' /�� rt. earl
uI tti; .,
NC Well Contractor Certification Number 15:,OUTER CASING�(for.m ed'*elis)OR LINER(if 4 Ucable)-
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 4Fft. 6.25 1' !,in. SDR-21 PVC
Company Name 16.INNER.CASING OR TUBING(geothermal`closed-taop)'
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: f� ft r� ft. i• ' in. id -9e / /,-
List all applicable well permits(i.e.County,State,Variance,Injection,etc) '7 c'1
ft. ft. 1 ' in.
3.Well Use(check well use): i
1Z SGREEN •. '. .,. �i: I
Water Supply Well: FROM ' TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft. It. in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft" ft to I
❑lndustrial/Commercial ['Residential Water Supply(shared) iS GROUT f: .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft.. 20+ ft' Bentonite ' Hydrate chips in place
Non-Water SDpply Well: �
OMonitoring ❑Recovery r ft, `ti c�R �r �'c J" f.,pikto �er{f
Injection Well: ft. ft. ! I'
❑Aquifer Recharge • ❑Groundwater Remediation •:19.SAND/GRAVEL PACK(if applicable) .•
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. ;' !'
❑Aquifer Test ❑Stonnwater Drainage
It. ft.
❑Experimental Technology ❑Subsidence Control 20,DRILLING LOG:(attach additional sheets if necessary).
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sa0/rock tppe,pratn size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © it Q. n' fi®/��t/ �,.
Completed:0���tr7 Well ID# a ft ft ,t lent f' dt
4.Date Well(s)
5a Well Location: A�f t. /q. ft. U'fj/Q e •'. _
f&ei c�lar 14- ft ft. i.::��
Facility/Owner Name Facility ID#(if applicable)
ft ft. MAN l ` 2014
7710 sWA_ D,o I i be rfy a
-- - ft ft .
Physical Address,City,and Zip tr10-trP i^-1 P.-^"r '°",„'tiny,
/� I�, �y �( 21.°REMARKS. . :'- , l ir:3x� .
C "e ► " "'-✓mil 3C/ /6� Wroof /, ste-r — Cal-
County
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: I '
(if well field,one lat./long is sufficient)
22.Certification:
N W /5'-/J / - . e>1 'io -a/
Signature b ertified Well Contractor Date
6.Is(are)the well(s): lerrmanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: lil es or ❑No 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 '
submit onefomm. SUBMITTAL INSTUCTIONS.
9.Total well depth below land surface: /YS - (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiPrent(example-3Q200'and 2®100) construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servicie Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY i 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 I,
(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
24c.For Water Supply&Injecti
13a.Yield(gpm) / on Wells:
� Method of test: Air n .
Also submit one copy of this,form within 30 days of completion of
13b.Disinfection type: granular hypocholrite- Amount well construction to the county health department of the county where
--/�� constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Wate Resources Revised August 2013
1I