GW1--05209_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:
BillyKennedy 14.WATER ZONES
enne y FROM _ < TO ___ DESCRIPTION
Well Contractor Name Ho ft. G/f ft. 190044
2834-A No ft. /re ft. Alitno
NC Well Contractor Certification Number IS.OUTER CASING(for mulitaM wells)OR LINER(if bie)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling e ft. 4$'1• 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal elosed400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3r ft. ft. tn.
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 DJ DER_ SLOT SITE THICKNESS MATERIAL
ft. rt. in.
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) Gilltrential Water Supply ft. tL in.
S/ g ' PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation
Non-Water Supply Well: ft. 20+ ft. Bentonite Hydrate chips in place
-
❑Monitoring ❑Recover ft. ft
y+
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERiwL EMPLACEMENT METHOD
ft H.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO D CRiPTION(color,hardness,eoiltrock type,grain sine,era)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 1#21 Remarks) o ft. 1 ft. ,'�
Q rt.
O/�� R Gt �I
4.Date Well(s)Completed:7-J-a Well ID# /0 V '�C'� `!
/Q ft. .3.13 ft. ere.IC
5a.Well Lo lion:
•� ft. ft.
j,�{l' t L' ke.S ft. ft. - - -
Facility/Owner Name Facility iOh(if applicable) ft. ft.
301 /i4ncon .._..-.__t_.. ft. ft ` r
Physical Address,City,and Zip 21.REMARKS J`P ') li -
Ai
fe- b000aaaa I,,:,..-
County Parcel Identification No.(PIN) ,_
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)' 7
�� N W Signatu` Ce/i0ed WellDate_9-.291
6.Is(are)the well(s): IQYermanent or OTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 04.4c 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 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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: e. O?,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-3@200'and 2(0100') construction to the following:
10.Static water level below top of casing: go (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing,use"`" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For lniection 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:
(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
J 13a.Yield(gpm) L"" Method of test: Air 24c.For Water Supply&injection ;'ells:
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
136.Disinfection type: Amount: /ao L
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013