GW1--02326_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy _14.WATER ZONES7.. T.'°-;',.-., , .
FROM j, TO DESCRIPTION
Well Contractor Name 7✓ ft• ro ft. 3
2834-A tag ft. o a ft' cam`
NC Well Contractor Certification Number
,15.OUTER (for:multi-casm.wells):OR'LINER(if ap Ruble) '
FROM - TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a ft• 01, .. ft• 6.25 j , SDR-21 PVC
Company Name :16 INNERCASING OR TUBING(geothermal closed-loop). '_• ''
�f`/ FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: A VA ft. , ft. in.
List all applicable well permits(i.e.County,Staftte,Variance,Injection,etc.)
ft. ft. I, in.
3.Well Use(check well use): £-
Wate pply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
gncultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '.18:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 - ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ;-19;SAND/GRAVEL PACK(if applicable), , , ;`4 :�` _ :
FROM j. TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ,
ft. ft. ,
❑Experimental Technology 0 Subsidence Control
20:DRILLING':LOG.(attach additional sheets if nece`ssaiy)r . :? -
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP N color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ) ft. ot ft. /J„7
f ft. ft. '�W/
4.Date Well(s)Completed: .3—13` �Well ID# l� /,1O r'i•G
/a 5a.Well Location: ft. ,�1� fr• / co
��// ft. ono[ ft. 10 code_
1=e ti, ,/,'!l-e/i ft. ft.Facility/Owner Name Fa fifty IDtyPPlicable) 4�s d ,°`' `
ft. ft.
C 7%'7 8 u o/t Foc ft. ft. A PR r 0.2024
Physical Ad ,City,and Zip .41: rw�o
REMARKS=';; f-' 1 ;e1AleXiaA 7/O3O?. If'�f ,�, I> . u � ' `'11rA
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)
4073777 N 7? &2 338i W & ,�ti ,o 3-43 d Y
Signature Certified Well Contractor! Date
6.Is(are)the well(s): ElPFFmanent or OTemporary By signing this form,I hereby certify'that the well(s)was(were)constructed in accordance
with I SA 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 C33Qo 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 one form. SUBMITTAL INSTUCTIONS , '
9.Total well depth below land surface: aaz (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@I00) construction to the following: I,
10r Static water level below top of casing: 30 (ft.) Division of Water Re�ources,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: 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) i Method of test:
AI r 24c.For Water Supply&Injectionl Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite ro well construction to the county health department of the county where
13b.Disinfection type: Amount:
L
constructed. I ,
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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