GW1--05204_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 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 30 ft. 3S-ft. /�
2834-A ft. ft. -�
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
FROM TO DIAMETER THICKNESS MATERIAL _
Kennedy Well Drilling 0 ft' ac rt. 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�/�_�OO^^��O/ O� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 5 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 ❑Munici lie ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustriaL/Commercial ❑Residential Water Supply(shared) IL OUT
FROGRM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well: 4
❑Monitoring ❑Recovery tt O �QCS
Injection Well: ft. ft. 'J
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM i TO DESCRIPTION(color,ha dness,soiVrock t)pe,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ` O ft. r ft. 4)4 s 74 j t,.,j
�g s ft. is-- It. RO GGGI!!
4.Date Well(s)Completed: ell ID# ,r ft. 61 rt. ��k'lNV�L
5a.Well Location: N ft. ft.t
✓/Gf0f, et god"/ 914e„ T ft. ft. ; lr
Facility/Owner Name
/� /r ( Facility ITV(if hirable) ft. n• S E P .� 2024
T4 ✓"`0/ n fTL�1 9Iet ft.
•
PI)) ical Addres,City,and ip J V y 21.REMARKS 11'• ,
4 o/,JP.�a are
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifsufficient)well field,one lat/long is
N w e—c)3-.=2"/
�� Signature u riifi We Contractor Date
6.Is(are)the well(s): L?PermaIIent 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 I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or QNo 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:
8.Number of wells constructed: / 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.
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: //0s1 2 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di/erent(example-3@200'and 1Q100) construction to the following:
10.Static water level below top of casing: /0 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: s•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) /,r- 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
13h.Disinfection type: Amount: /OOe_
constructed.
I in ni OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013