GW1--06206_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Bill Kennedy ,14i.WATER'ZONES, , i, J.l
Y y FROM TO DESCRIPTION
Well Contractor Name ft. riz ft. 1
2834-A ft. O"`/ ft. �71 :
NC Well Contractor Certification Number
r•IS.OUTER CASING(for multi-cased'Wells)OR-LINER i(If ati liable)FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling d ft 60 ft 6.25 SDR-21 J PVC
Company Name 16.INNERCASING OR TUBING`.(geothermal closed-loop) :..-7,',:::,,..;.'-
^� /! FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: r0CX41-- er 0 ft. ga ft. if i hi. 5 _/ ,'°,
ce
List all applicable well permits(Le.County,State,Variance,Injection,etc.) ( G� 7 U
ft. ft. ' in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) IRI14.s.idential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT ,;,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irigation T-- ft. .28+- ft - e
Non-Water Supply Well:
❑Monitoring ❑Recovery ft !IGt, ea ft ' 4 fete-eof ,tt -A6r-
Injection Well: it ft. /015.
f,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(rf applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fit ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology 0 Subsidence Control ?-20.DRILLING LOG.((attach additional sheets if necessary):;*;.,-,
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)� ^^ ❑Other(explain under#21 Remarks) D ft. .v ft. ,it
4.Date Well(s)Completed: ��®IX Vell ID# so ft. G o ft U,( u� //v1 r f�
(�
5a.Well Location: /0 ft 1 G0 fit. j/ice tg7fa�)(�
ft t!/ ft
l�sb4_ ;. ., _4 ..
fan �f �J� ft ft.
Facility/Owner Name Facility ID#(if applicable) ,
n ® ft. ft. ;, OCT � 1 �Ut.4
3a3a �a �� `�' ft. ft. , r<
Physical Aopt,
_1/4d City,and p
21�REt�A,RKS
,7G 7 'J6 cc233 ' 'v""l grog +�` •- 4r��Q.Si1�� Aid-
County Parcel Identification No.(PIN) C 4- -/
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: !3/bIJK �S ,/./r/I/
(if well field,one latllong is sufficient) ,dig 9_'A yi
N W �C/II� �<� / e t/ a
Si Certified Well Contractor,CC// Date
6.Is(are)the well(s): ermanent or OTemporary By signing this form,I hereby cert(ly 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: 2i'Yes or ❑No 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 j,
repair under#21 remarks section or on the back of thus orm. 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: NA construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells 0 Ywith the same construction,you can
submit one form. �1 P SUBMITTAL INSTUCTIONS
I.
9.Total well depth below land surface: eX(90 (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'andd72@100) construction to the following:
10.Static water level below top of casing: sV (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 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rot ary 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
(Le.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) B' Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Hypochlorite Amount: •"W/Z well construction to the county(health department of the county where
constructed. 1
1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013