GW1--05203_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name S `ft. O ft.
V At
2834-A me"- 110 ft" Sr p�+t /goy /0 #
NC Well COrlliai lltt Certification Number 15.OUTER CASING(for mul ased wells)OR LINER(If ap Scab!
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 53 R' 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#: f�1 - 00001i/38 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injrrnmi.et, )
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
ft. ft. in.
['Agricultural 0 Municipal/Public
❑Geothermal(Heating/Cooling Supply) 13Restdential Water Supply(single) ft. ft. in.
❑lndustrial/Comrnercial ❑Residential Water Supply(shared) 1$.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. /L 66,S
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
R. R.
[Aquifer Test ❑Stormwater Drainage
ft. it.
['Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. 3 ft. GAC/J r
p 3 ft. '1 o ft
4.Date Well(s)Completed: O-/(y-a.�Well ID# D�(/ "raj",
I✓
J�/ft, 4 "A'u v
Sa Well Location: t t203 ft. / Ili /.D
6 ft Air✓ k kli/e# g._fft.
ft. ft.
pt([ l
Facility/Owner Name Facility ID#(if applicable)
•
ft. ft. I 3 V P ') ` 2024
6/K7 :-vs lw ry T t.vn RI ft. ft.
Physical Address,City,and Zip - • `-
/ 21.REMARKS IC,`J• •'`
Qa ai%oh c(61q 14373--7
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 W � ' o�j
_/6 -ay
� Signature edified Well Contractor - Date
6.Is(are)the well(s): ErPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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
8.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. TTL
�^ SUBMIA INSTUCTIONS
9.Total well depth below land surface: a03 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di(jerent(example-3 a4200'and 2(4100') construction to the following:
10.Static water level below top of casing: p.L7 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl 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
Air 24e.For Water Supply&Injection Wells:
13a.Yield(gpm) © Method of test: Also submit one copy of this form within 30 days of completion of
granular hypochoirite well construction to the county health department of the county where
13b.Disinfection type: Amount: P-OZ
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013