GW1--02944_Well Construction - GW1_20240513

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
.14.'WATER'ZONES . 1Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name 7 to d/ ft. i, /D ft.
2834-A ft ft. C `��
NC Well Contractor Certification Number 15,OUTER CASING(formulti-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft"
of 3 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#: 0f/ - 3/0e, ft ft. 1 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 apply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gncultural ❑Municipal/Public it ft. ill'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. io•
0 Industrial/Commercial ❑Residential Water Supply(shared) YS.GROUT
FRODI TO DiATERiAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ it• 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 0 Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft. •
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary). 5'
'❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) e ft 6 ft C.!
4.Date Well(s)Completed:3 L .—t . Well ID# & ft I/o ft /cifail - ''et
5a.Well Location: km ft Ss ft. 8� / r,
�p� f gJ/�ST��
r"rV Cral )o s'1 .7J ft POL7 ft. ' -L • ' . a_._.q)
Facility/Owner tame Facility ID#(if applicable)
ti i cq L;1## t eo ri r, SIV IG /1/ ft. ft. MAY I - 2024
Physical Addres Cip and Zip 21.REMARKS-" y. ' Yi
4010 t 4 7. 9tOif 1t2O I: tr.�., r.`..(i 3, <<?,
County Parcel Identification No.(PIN) I:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one 1at/long is sufficient)
3 .s701s-& ' N 76, 6, ? ?g/6 w iSd f 3-/S=J 1
�f Si ed Well Contractor Date
6.Is(are)the well(s): f?l'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l o 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 oldie
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
S.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: c - (ft.) 24a. For All Wells: Submit thus 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:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servic I Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in-) 24b.For Iniection 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.)
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(gym) (1, Method of test: i
Also submit one copy of this form within 30 days of completion of
granular hypocholrite // .2. well construction to the county health department of the county where
13b.Disinfection type: Amount: O�
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013