GW1--04581_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kennedy14.WATER ZONES
Billy FROM TO DESCRIPTION
Well Contractor Name hay ft. Ja/ ft. 45,ttet
2834-A /eft. «S ft. � ,k
NC Well Contractor Certification Number 15.OUTER CASING(for mullionedwells)OR LINER(if cable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft• s-7e ri. 6.25 SDR-21 PVC
Company Name 16.INNER CAS G OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 31910101 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 ❑M icipa1/Publie
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ['Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soli/rock type,grain sue,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. 6 ft.
e_t/C,/ /- ft. die ft. . / :, r
4.Date Well(s)Completed• l47 ,Well ID# C� (�/ �C/J�(/T/
SiO ft. SO ft. /,tL�IEFt n ,,
•
5a.Well Location: _(SV ft. a�V03 ft. /VrN t I .
ft t: Ic k r ft. ft. _,- • * J �)
Facility/Owner Name Facility IDH(if appbcaotet ft. ft. ��"-"�'r�.
SIP e I-441 l 4, ft. ft. j 0 L 3-1-724 -114
Physical Address,City,and Zip ✓
tt
,�j� /�/�� n,_Q� 21.REMARKS g.e ,
!IL���/` ,00a az. N 11 :f' ti:^.%i ii
( ems
Cou�y`: 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 ,W (y '�`S=a�
Signatu f Certified Well COnttacto Date
6.Is(are)the well(s): r7Peftnanent or OTemporary Lty signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or GiNO 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: 963 (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 a( 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 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
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:
(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) 3 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: 61 Q7
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013