GW1--06207_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Keened ;1a:-WATER ZONES '_ ;°
Y y FROM TO DESCRIPTION
Well Contractor Name !
2834-A ��ft. `� t. 6, 1
r-15:OUTER CASING(form ultt=cased"wells)OR'LINER(if ap;iteable) "'
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft- ft 6.25 ; in• SDR-21 PVC
16.INNER CAS G OR TUBING eothermal closed-loO' . t: `_:i
Company Name (>; P) " ��-� �_-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: c' 0000.21,33 ft. ft in.
List all applicable well permits(i.e.County, ta�ance,Injection,etc.) 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) residential Water Supply(single) R ft in.
❑Industrial/Commercial ❑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.
OMonitoring ❑Recovery 'h45,1
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ;, 9.SAND/GRAVEL PACK-(if applicable), -
6
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Battier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
%20.,DRILLING',LOG(attach additional sheets:ifnecessaiy)4. ',' ,`
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) '
❑Geothermal(Heating/Cooling Return) 1❑Other(explain under#21 Remarks) tJ ft. /f ft. _ ey
4.Date Well(s)Completed: / !O Oi; 'dll ID# <p ft 30 ft �Qr®�Gis_
30 ft .�1 ft. SGJ
5a.Well Location: ot067 FF
ft. ft. Y `t'l.t:. L.i .
A'tst1 e f V. 7,-,kv. , ft ft. t
Facility/Owner Name Facility ID#(if applicable) ft ft. 0 r T 9L 2024
!r r r
I s�9 itn �.� ft. ft. !r,.. :' t
Physical Address,City;and Zip r` t r,
�31.REMARKS';`� �'
/4o,.1e lfoi 760 9o9-9G.a,3tL i! 3 Feet` vt,;t of- „co" sg-
County Parcel Identification No.(PIN) o NI k _/ r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ,Tj! •
(if well field,one Iat/long is sufficient)
N W 1 (,4SdCertified Well Contractonf! Date
6.Is(are)the well(s): permanent or OTemporary By signing this form,I 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 @iVo 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 w,ell:detaiis:
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 fornz. ^^ 11 SUBMITTAL INSTUCTIONS
t>LOG
9.Total well depth below land surface: 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 2Q100) construction to the following: I
10.Static water level below top of casing: 4/10 (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 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:
(ie.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) (p Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forin within 30 days of completion of
Granular Hypochlorite well construction to the countyhealth department of the countywhere
136.Disinfection type: Amount: ia4L_ ep
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013