GW1--02335_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: I1
14.WATER ZONES {'":.
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name �bt 7l ft. 3a r ft. /��/•
1
2834-A ft. J ft. ✓'"
15:OUTER CASING(for multi-cased wells)OR LINER'(if Op 6cable)
NC Well Contractor Certification Number
FROM TO DIAMETER. THICKNESS MATERIAL
Kennedy Well Drilling a it- 40 ft- 6 25 'in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) "
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: //6_CO ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) -
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN ' '; .
Water Supply Well: FROM To DIAMETER' SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
OAgricultural ❑Muni ' al/Public
❑Geothermal(Heating/Cooling Supply) F3Residentlal Water Supply(single) ft ft in•
❑IndustriaUtnn Cmercial ❑Residential Water Supply(shared) 18:GROUT .
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 0 Groundwater Remediation 19.'SAND/GRAVEL.PACK(if a cable)
Pp'h '
FROM TO EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL
ft. ft
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
DExperimental Technology ❑Subsidence Control
20 DRILLING LOG(attach additional sheets If necessary) • ,'!i,4^-c
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(co r,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. 3 ft. „ / _ LI—
4.Date Well(s)Com leted:3—g—a L�` Well ID# 3 ft' /0 ft. b- e' "-�
P /O ft. L, 2�7 ft. /l_E��e k.
5a Well Loca�ion: ( ft. ft. A n 2 .'y..-.'i' t,:..
/ s _' \�Eq .-•. �_. i i' i L••
ft. ft. ,-
'Facility/Owner Name FacilityIDtl(if applicable) ft. ft. ! APR 1 2024
is-s-a t. v O/a,t / cAretch 4, ft. ft. ;-- °�
ITI;Gi7 ..,f;t ? )F. t to
Physical Address,City,and Zip/ ///__
���tyYl �!(o�p 21.REMARKS�"�.,. s •,, .-,,_; r;is`Na^.rj'?rl( °'''
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)
r ?
N W v--e—a7
��, Signature o edified Well Contractor Date
6.Is(are)the well(s): l0l'erinanent or ❑Temporary By signing this form,I hereby certify 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 l3No 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
:t:. S.Number of-wells constructed: / construction details. You may also'attach additional pages if necessary.
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For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form.- ' SUBMITTAL INSTUCTIONS '
it, 9.Total well depth below land surface: /02 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
3 For multiple wgjlslipt all depths i different 3 00'and 2 100 construction to the following: 1'
P f (example- @2 @
'11!.-.Static water level below top of casing: /et/ (ft.) Division of Water Resources,Information Processing Unit,
Ijwateer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l
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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this foimn within 30 days of completion of
granular hypochotrite
13b.Disinfection type: Amount: /V/0� ,well construction to the countyhealth department of the countywhere
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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