GW1--02333_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 s ft. ft. T
2834-A 7rft. 7g ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multaerSed wells)OR LINER(if ap.licable).
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling p ft- ct/ ft• 6.25 ; , in. SDR-21 PVC
Company Name 16:INNER CASING OR TUBING.(geothermal closed-loop) `-' "
Y FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: S II Y ft. ft. l' 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geotheal(Heating/Cooling Supply) esidential Water Supply(single) ft' ft. in•
rm
❑IndustriallCommercial ❑Residential Water Supply(shared) GROUT ,_FR18:OM 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) .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft-3
❑Aquifer Test ❑Stormwater Drainage it. ft.
❑Experimental Technology ❑Subsidence Control 20.sDRILLING LOG(attach additional sheets if necessary)° ,
❑Geothermal(Closed Loop) OTracer FROM TO DESC,y(2IPTION(color,hardness,soWrocktype,grain size,yetc.)e'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft.1 ;9 •1,/ ft. /)'",1-
L f ft. is[[- ft. A fo i rt
4.Date Well(s)CompletedL !/ Well ID# -I
IS— ft' Y 3 i• 4 rod-e.
L _ __
Sa.Well Location: ft. ft..
6re`Q_r — t �T,l� !k ..-�/IQI� ft. ft. i �.s. r,7-- `. !n' .;-
Facilit�/ wner ame Facility ID#-(if applicable) ft. ft. 'rL..S�V.:► V 3....j,,•
7,3) Ed[L�rrdS /1III!/ `de",Cs ti ft. ft.
APR_ 1 0 2074
Physical
Address,City,and Zip
Cic •
21:REI4ARKS'+'.
`v-� SVr fn7etFP7+ari1 Prr:wergng(iFi _
County Parcel Identification No.(PIN) �
m.i4`vt 3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35_' (:� a 7n3fs N 79r Gs� W , �' 3-/- 02 y -.
� Signature,11.Celt ed Well Contractor Date
6.Is(are)the well(s): Cif manent or ❑Temporary By signing this form,I hereby cernfy that the well(s)was(were)constructed in accordance
with 15A 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 ET1Vo 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 fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 63 , (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 2Qa 100') construction to the following: I '
10.Static water level below top of casing: /6' (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:i In addition to sending the form to the address in
24a above, also submit a copy of 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.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 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:
OZ.- constructed. i
1
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013