GW1--02941_Well Construction - GW1_20240513

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name 7,ft. a Fi a ft. L/9P/yt
2834-A /Taft. / ft. r eft,
NC Well Contractor Certification Number 15C OUTER'CASING(for m -ca ve11s)OR LINER:(if ap licable) "
FROM TO DIAMETER' THICKNESS MATERIAL
Kennedy Well Drilling O ft• 6s'--ft• 6.25 I in* SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)::..
�� OOODO3 9 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Y
iance,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.
❑Agricultural ❑Munici al/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) i8.GROUT -• '`
FRODf TO MATEIIIAI. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ it Bentonite Hydrate chips in place
Non-Water Supply Well:
. ft. ft.
❑Monitoring ❑Recovery .
Injection Well: it. 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 ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) ' '..
DGeothermal(Closed Loop) OTracer FROM TO DES ION(color,hardness,solFro ck type,grain size,etc.)
OGeothennal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ® ft. ft. Ghft te A
4.Date Well(s)Completed: Al It-al/Well ID# I/ f L S0 f L i3ro_ '•'-- roc _
ft. 4°3 ". rvdc �! . ' t_, ,7-.: ._
5a.Well Location: ft. ft. ii .� .', .,•i V . i
• Satnes mur/a.y ft. ft. MAY 1 2024
Facility/Owner Name / Facility ID#(if applicable)
ft. ft.
•- - //kS &r e ell Pa/'d 1 4 ft. ft. lr,��r� r,.:t
Physical Ad s,City,and Zip i i r
ka o�1, 773a,fs3'q ye
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W Z \ 4_ 6-aC
�� Signature f erti/< e -
Well Contractor Date
6.Is(are)the well(s): 1211 ermanent or OTemporary 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 E S 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a03 (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 2@100) construction to the following: j
10.Static water level below top of casing: (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 Infection Wells ONLY: In addition to sending the form to the address in
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
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&Injections Wells:
13a.Yield(gpm) �O Method of test:
Also submit one copy of this form within 30 days of completion of
granularhypochelrite 13b.Disinfection type: Amount: `010 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