GW1--06204_Well Construction - GW1_20241021

I.
WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells '
1.Well Contractor Information:
14.-WATER ZONES. i_ ', - : .
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name OV®R, ft. i
2834-A rt. ft
NC Well Contractor Certification Number IS.OUTER CASING(for.rindti.eased:wells)ORLINER-0f'ap itcable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a ft. 60 ft. 6.25 in. SDR-21 PVC
Company Name ,..16:INNER CASING OR TIURING(gcotbcrniaiclosed-loop). :-- ' ' ..
FROM TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit#: 02 di owed r, 7 ft. ft. in. •
List all applicable well permits(i.e.Comity,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17'SCILEEN
Water Supply Well: FROM TO DIAMETFst SLOT SIZE THICKNESS MATERIAL
ft ft In:
❑Agricultural ❑Muaicipal/Public
❑Geothermal(Heating/Cooling Supply) Rttgrential Water Supply(single) ft* ft in.
❑lndustrial/Columercial ❑Residential Water Supply(shared) FROM
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ it Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft /� /-
❑Monitoring DRecovery Q�
Injection Well: ft. _ ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(if malleable) .'.' ---
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier R. ft.
❑Aquifer Test ❑Stomiwater Drainage
• ft. ft. I'
❑Experimental Technology 0 Subsidence Control .20.DRILLING additional sbeets`ifnecessa y)•..'-..-.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESC'i rN(color hardness.saatrocktype,grain else,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. /� ft. - FI 6k
4.Date Well(s)Completed:7 C/ OL I/Well ID# g ft g
IL %;,„ st_e.,_
5a..gWelll Locc lion: ft. ft. / '— ' a
I
Ft ft
Facility/Owner Name � Facility ID#(if aapapplicable) R. R. 1 OCT J T J Ii [u l/i
�q7D A!^ rA l `'r "e I`( Ad ft. ft. IIIJ i
Yi.C;t . 77-7•
Physical A- dd s,City,and Zip (/P ,�J�-- r215REMARKS•' 1.r i t it v.:' . .
•
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 6 ; / i‘e.-7-n-id 7-.)3--,a1
Signature•-fr ertifed Well Contractor Date
6.Is(are)the well(s): 2147manent or OTemporary i
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 biro 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 i
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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 42,p S (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@100) construction to the following:
10.Static water level below top of casing: .579 (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 ('m.) 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: i
(i.e.auger,rotary,cable,direct push etc.) Division of Water Resou ices,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
9 Method of test: Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) (!+ Also submit one copy of this t form within 30 days of completion of
Granular Hypochlorite A well construction to the county health department of the county where
13b.Disinfection type: Amount: /6®Z. constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of W i ter Resources Revised August 2013