GW1--02943_Well Construction - GW1_20240513

I
WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
14-WATER ZONES -
N. ,
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name e)ft ^/fj1 ft /A'fq jI
2834-A OfOL ft. ��/ fL �7(/V/"
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap iicable)'
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 fL /ale ft. 6.25 ' 1°• SDR-21 PVC
Company Name 16INNER CASING OR TUBING(geothermal closed-loop) '
�//�� ('e 00�y _ FROM TO DIAMETER THICKNESS MATERIAL
oCV
2.Well Construction Permit#: a q ' goat o fL If® ft. `(o' in. ��?.G�./ 90 T/)v�
List all applicable well permits(Le:County,State,Variance,I jection,etc.) /
ft, ft. ' in.
3.Well Use(check well use): . ,17.SCREEN, -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public _
❑Geothermal(Heating/Cooling Supply) gSiential Water Supply(single) ft. ft. ill.
❑Industrial/Commercial ❑Residential Water Supply(shared) FRoni _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. o It. .J_J_ //id1
❑Monitoring ❑Recovery f r
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
❑Experimental Technology 0 Subsidence Control 20 DRILLING LOG(attach additional sheets if necessary)' _ `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q fft. ft. claw .L/ .� ell ID# s ft r�9 fl , /�_ 10
4.Date Well(s)Completed: 7 OI4�O�W P/ O // s nef �id�
Zi D f t /00 ft' leSf8 ✓t-e-
5a.Well Location:'V if
ri ft. 2 ft. /,fie -. /. _ _ im
e �/rl/'�ytr ft. ft a b..�.,,i:.:.r 1V 4.,.,)I
Facility/Owner Jame Facility ID#(if applicable)
t13o3 5 1 (roae. C Lice i d ft. ft. MAY20?4
Physical Address,,City,
¢and Zip G/� t �
XJ®!/g' ` �+ 124731 IO -! .21:;REMARICS ... tr; ., c D r r ? ,)•.s�:
ri rct-,303
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient) At'
- - �l,�- L,/
N W 1CAt' !�-L �� ! [
�� Signatu if Certified Well Contractor Date
6.Is(are)the well(s): &Permanent or OTemporary By signing this form,I hereby cert fy 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 &SO 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#2I 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 nnnitiple 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: ram/_6J (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: ; '
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 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: rotary constmction 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) t. Air 24c.For Water Supply&Injecti n Wells:
�Q Method of test:
Also submit one copy of this form I within 30 days of completion of
granular hypocholrite ,�o} well construction to the county health department of the county where
13b.Disinfection type: Amount: constructed. i I
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013