GW1--04563_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This farm can be used for single or multiple wells I
1.Well Contractor information: 14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
�� ft. /ye? ft. �-
Well Contractor Name /� ft.
2834-A OUTER L'AaING(for mn irdid wells)OR LINER(lisp Itcable)
NC Well Contractor Cettlikation Number FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft• ` (,/a,(r n-16.25 'n• I SDR-21 PVC
16.INNER CASING OR TURING(geothertrtai dosed-loop)
a^. Name FROM TO DIAMETER THICKNESS MATERIAL,
ft. ft. DIAMETER
2.Well Construction Permit#: ._ to
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft
3.Well L'ac(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS . MATERIAL
Water Supply Well: ft. ft. In.
icuitural ❑Municipal/Public ft ft. In.
❑t.ieothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
18
❑tndustrialiCommerciat ❑Residential Water Supply(shared) iS.GROUTTO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fL 20+ it. Bentonite Hydrate chips in place
Non-Water Supply'Nell: ft. ft. /3
❑\ionitoring ❑Recovery ft. ft.
Injection Well: 19.SAND/GRAVEL?ACK(if applicable)
r�iAgitlfCr Recharge OGrotmdwatcr Rcmcdration FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery OSalinity Barrier ft. ft
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20,DRILLING LOG(attach additional sheets if necessary)
❑Geothtrmal(Closed Loop) DESC
❑Tracer FROM TO RI ON(color,hardness,soil/rock type, ram sift,ete.l
ft, ft. �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 10 10
p ft. ft 1/p 46434/I'L Art
4.Date Well(s)Completed:7 a VWell ID8 ; 0 [t• ft• `_,roeir._
5a.Well Location: !I It. n. K
' s 1;
Facility.'Owner Name Facility[DN(if applicable) ft. ft `; :..:1..•. v c. L •1
3y6/ ,A4cir '1 Form Ad ft. ft. tG24
Physical Address City,and Zip
21..REMARKS J J L 3 _
k, Q/A f/Gl to03�310 - .-g t;,.
• Parcel Identification No.(PIN) D:r: . 3
County
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(it well field,one)at/long is sutticiem) �� //' /A 1(�
t35�(og/4T_ Q / ? ��' Date`J O�
2 N 7/ c ✓v 8'D70 S�g�a"` fCeRified Well Contrac r
6.Is(are)the well(s): j anent or ❑Temporary By signing this form,I hereby certijb that the well(s)was(were)constructed in accordance
��/ with ISA NCAC 02C.0100 or 13,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or
GA(' 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 23.Site diagram or additional well details:
repair under#z1 remarks see Tian or on the back of thisf You may use the back of this page to provide additional well site details or well
/ construction details. You may also attach additional pages if necessary.
8.Number of wells constructed:
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUGTIONS
submit one form.
aa3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
9
F.r multipleal wellw deptht all below sland surface: construction to the following:
For wells list depths if different(example-3(aL00�and 2(a1100�
1
�° (ft.) Division of Water Resources,Information Processing Unit,
If water lnerc water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
ije(is above casing,use,•�.,
6.25 24b.For Infection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: Om) 24a above, also submit a copy of this form within 30 days of completion of wel
rotary
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
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
granular hypocholrite /1 well construction to the county health department of the county where
13b.Disinfection type: Amount: f ,istLconstructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013