GW1--05206_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:
BillyKennedy14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name rS.-
fL6 G ft a i�.see
2834-A � ft. rity ft. o141 /SI
NC Well Contractor Certification Number 15.OUTER CASING(for multi-ease
d'Wells)OR LINER(If a tics ble1
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling D ft- !t, i fL 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#: Sos97 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Lyection,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 ❑Municipal/Public In.
� ft. ft. In
❑Geothermal(Heating/Cooling Supply) IiKKesidential Water Supply(single) _
❑lndustrial/Cotnmercial ❑Residential Water Supply(shared) 18.GROUT
FROM 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 Remcdiation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
0 Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft' /O it. /J's��,/J&/a�/
4.Date Well(s)Completed: J Well ID# !0(..r:It.___,s/ ft. idre ^ [i /`��
5a.Well Location: t 03 ft• PV �ft. ft.
1OI►n .5 Gett ft. ft. SFP :) �G?_4
Facility/Owner Name Facility ID#(if applicable)
//��
'' // ft ft
T6 d A'ej •ems 6 CLt roam- M/t4 Al ft. ft.
Physical Address,City,and Zip 21.REMARKS . .. ., .,
,4too'G 0400Koas�
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 `/ r�
gnn%��gL[ ti a _/«`a�
Signature ertt led Well ontractor Date
6.Is(are)the well(s): [Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or !Writ.--
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 tfe same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30.3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-300'and 2(a1100') construction to the following:
10.Stadc water level below top of casing: ,5°- (g.) Division of Water Resources,Information Processing Unit,
If seater level is above casing,use"-•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 51 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 well construction to the county health department of the county where
/a
13b.Disinfection type: Amount: OL
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013