GW1--02329_Well Construction - GW1_20240410

WELL CONSTRUCTION RECORD +
For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Billy Kennedy FROM
wATExzONEs . DESCRIPTION
Well Contractor Name tDf/ ft. a R• 3
2834-A 73.- ft. 7.E? ft. I
NC Well Contactor Certification Number "15.OUTER.CASING:(far.inulti- sedwells)ORLINER(ifap licable) '.
FROM TO DIAMETER I THICKNESS MATERIAL
Kennedy Well Drilling 0 ft• ,3-0 ft. 6.25 1 in- SDR-21 PVC
Company Name .;16.INNER CASING OR TUBING(geothermalelosed-loop) '-'..:;i;";:i"?..,:-
^n nn FROM TO, DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0��3 - 0000 t s 3 ft. ft. • i' in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL.
❑Agricultural DMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft' ft' in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 20+' ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft. i.
❑Monitoring ❑Recovery
Injection Well: ft. R-
❑Aquifer Recharge ❑Groundwater Remediation 19.-BAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experirriental Technology ❑Subsidence Control '20.DRILLING LOG(attacli additional sheets if necessary) ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)_ 0 ft. 3 ft. C /-
4.Date Well(s)Completed:3 3'c7i Well ID# 3 ft /Q ft' I0' 5e' (Yak_.
/2 ft. t c2 ft. s 1
5a.W ocation: ! ft. J ft. /v
/ tiV
's i/5?2,1 Q /vtv/'Q n ft. ft. 1( 4s.r .,s R p 1. i ti l+0
Facility/Owner Name Facility'Off(if applicable)
i.:::::Y
ft ft. ,
_L/',(e:9 4t'f 13 7' ft ft. APR 1 0 2024
Physical Address,City,and Zip
/ l'.o/4Q / 7/ - Oa�i/976e ,"21.REMARKS _ '',+ _ {rMci r•
,:a. it
y U?i
SeCl '
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)
?
N. w � � tJ,5=c23
�'Pe� Sigaat� fCertifiedWellContra Date
6.Is(are)the well(s): fdrmanent 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: • ❑Yes 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 welIdetails:
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 i.
9.Total well depth below land surface: acz,3 (ft.) 24a. For All Wells: Submit this form within 30 clays of completion of well
For multiple wells list all depths i different(example-3 00'and 2 100 construction to the following:
P .f@Z @ �
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,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 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:
(ie.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) O Method of test: Air 24c.For Water Supply&InjectioniWells:
Also submit one copy of this form within 30 days of completion of
granular hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount: 44a0 constructed
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013