GW1--02865_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy '1'4'WATER'ZONES .--4 ' '
FROM TO DESCRIPTION
Well Contractor Name ado ft a7 ft // 3gotit
2834-A ft. ft. W
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells){OR LINER(if ap licab►e) `
FROM TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling d ft ks- ft 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 11gt.r:-. p2 ft. ft. 1 in.
List all applicable well permits(i.e.County,State,Variance,L jection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: _FROM , TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni "pal/Public. ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) P,Ksidential Water Supply(single) ft. ft. is
18.;GROUT, Jr' -
❑IndustriaUCommercial ❑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
OMonitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ', - ."
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft. ,
❑Aquifer Test ❑Storniwater Drainage
ft. ft. •
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) "•r
❑Geothermal(Closed Loop) ❑Tracer MOM TO DEECRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)en DOther(explain under#21 Remarks) 6/ it. it jl e,.i-
4.Date Well(s)Completed: —y Ot / Well ID# '1 ft r-yI ft �/j���H ��
5a.Well Location: -
It. ft. �•'�
�tt 1
�A en rl l//I�.S /JGII�✓tC,yv ft. ft.
Facility/Owner Name `--/ F illy ID#(if applicable) MAY
Y 1 v 2024
y� / D� ft. ft. I l I
_���� Llfl Ce /1 j/ AEG/ ft. ft. _
Physical Address,City,and Zip -21.REMARKS`' " _ ro"a(rV..r,. °',:'
Mare- • me/ s"�
- ---- --- - --
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient)
N W 1 9s aV
rgna f Certified Well Contra Date
6.Is(are)the well(s): 21I'ermanent or ❑Temporary By signing this form,I hereby certify'that the well(s)was(were)constructed in accordance
�_� with I5A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I 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 detaiis:
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 it jection or non-water supply wells ONLY wit r the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: e2g 3' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1/61 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6'25 (in-) 24b.For Injection Wells ONLY: 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: It
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: Air 24c.For Water Supply&Injection Wells: ,
/ ec Also submit one copy of this form within 30 days of completion of
granular hypocholrite
13b.Disinfection type: _ _ Amount: /G well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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