GW1--02330_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:
.14.WATER ZONES ` . I . -
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name 7�ft Fg ft /off
•
`�
` 2834-A ft. ft.
NC Well Contractor Certification Number ,IS:'OUTER Ci1SING(forinidd-cased:wells)ORLINER'(ifap Iteable). .. ".
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ® ft g® ft. 6.25 ; 'in- SDR-21 PVC
Company Name 16.INNER CASING OR.TURING(geothermal closed-loop). .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well permits(i.e.County, tate,Variance,bjection,eta) ft. ft. iin.
3.Well Use(check well use): -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Munici al/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation • 0 ft. 20+ it 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) ... : , ., _'. , -.
FROM 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 necessary).. . .. .
❑Geothermal(Closed Loop) OTracer • FROM TO DESCRIPTION(color,hardness.son/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 3 ft. 7^ Sao`
3 ft i0 ft
4.Date Well(s)Completed:3`OZ� O Well ID# I�/�
Sa.Well Loc /0 ft. -Y0 ft. dl , s e
70 ft. 293 ft. 8 f�
RtlG.f" �CGrss�el
atio ft- aW ft.
•
r/ Facility/Owner Name Facility ID#(if applicable)
/� Pleet.k RI k�o et. s ft. ft .-.
Physical Address,City,and Zip 21..REMARKS.:'•,
,Aleof eaoads1/43,3 _ APR 1; 0:ZGZ4
County Parcel Identification No.(PIN) s P� .4 i
trM 1 T."-A0r,i1 �z ,5arir7:g L 3t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: t)WQ 3OC
(if well field,one 1at/long is sufficient)
N W /34'Y 'i% 1. �3'-ace -.)9
�� Signature o e We Contractor; Date
6.Is(are)the well(s): 14Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fl'1Vo 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
S.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: &'a3 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-.3Q20000'and 2®100') construction to the following:
10.Static water level below top of casing: 2 5 (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 df this form within 30 days of completion of well
12.Well construction method: rotary construction to the following:
(ie.auger,rotary,cable,direct push,etc.) i.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
1 13a.Yield(gpm) la Method of test: Air 24c.For Water Supply&Injection Wells:
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: /Of ex constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013