GW1--03195_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kenned 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name R 70 It. 16
2834-A 10Oft. 17) ft. y ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi wells)OR LINER(If ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. oZ ft 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING l eothermal closed-loop)
�/C�/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: U /o/ ft. ft. 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 Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) (ential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) iL GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ n• Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer 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
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.sod/rock type,grain lice.etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. ,.7 ft• /;/1t
tt ac- rt. L dr I f
4.Date Well(s)Completeds.7'7-c Weuu ID# '� -
5a. ITI
Well Location: - I---ft III �'• :,a r._ .
�' tth ,1-40ivi fl;t`a Sri ft. ft. �;�= �..`.; vi.-- A
Facility/Own Name • Facility BM(if applicable)
Co�3 /2a./,A Sf�� Al ft.
ft. ---.-MAY 2�" 2024
ft. ft.
Physical Address,City,and Zip 21.REMARKS - : '} ° 'y sr,i(
c ,N gyoi _..11
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W Al S 7-ay
�� Sigma Certified Well Contra Date
6.Is(are)the well(s): I�Ye:manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0M- 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
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: Sii3 (ft,) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if Afferent(example-3(l200'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 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
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:
(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
13a.Yield(gpm) 0)_ Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granularhypotitolrite Amount: /(po�_ well construction to the county health department of the county where
constructed.
i c,rm c.0 N'-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013