GW1--03873_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 1144.MATER ZONESO TO DESCRIPTION
Well Contractor Name jM ft. /�n ft. P•1(
2834-A 145-rt. /5 ft. / 4+
NC Well Con Factor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. no ft• 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
SOIG� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 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
ft. ft. in.
❑Agricultural ❑Mu�nicipal/Public
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) k. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.
PROMGROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft• 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)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft S' k• 4,-
/ L�
4.Date Well(s)Completed:J_VO (Well m# S. ft 30 p
L R 7o ft' f! .� �et-S G
5a.Well Location: ft.S&5as1 1o✓►&5 'ID ft t�'13 ft l , a -
Facility/Owner Name Facili (if applicable) I.f.._ `.1 .i
ft. ft.
7a0 Avower ,sMel ft. ft. JUN 17 8 2024
Physical Address,City,and Lip 21.REMARKS
11400cg Mao9ai 7 info x'.ai:`',r .w,. ate: 4 Ufa
cxi.C.,IL t:
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
n
N W A /e-02}
� Signs of ertified Well Co or Date
6.Is(are)the well(s): erermanent or OTemporary By signing this/ores,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 Cflo 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: O/)V (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@)100) construction to the following:
10.Static water level below top of casing: ,>f/ (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:
(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) /i5 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: granular hypo holrite Amount: Jae Z 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