GW1--06219_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 14.WATER'ZONES .r,. :I,•'
7 Y FROM TO DESCRIPTION 77
Well Contractor Name / Sf. /65' qa rd m y
2834-A ft. ft. [J
NC Well Contractor Certification Number ''.15.OUTER'CASING(for:multi-cased wells)OR'LlNER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. a ft 6.25 SDR-21 PVC
Company Name ,16:INNER-CAS G ORTUBING:(geothermal-closed-loop) . .- ,''.-. 2.' '!;,:,;: ,'u
,� /� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J 7l ft. ft. in.
List all applicable well permits(i.e.Counry,State,Variance,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) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. . ft. /D j`f
Injection Well: ft. ft. �J�
❑Aquifer Recharge ❑GroundwaterRemediation .19.'SAND/GRAVEL-PACK(i applicable) ' ' r-.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology 0 Subsidence Control
20:DRILLING LOG(attach additional`sheets if necessary); s , a=;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal(Hearing/Cooling Return) ❑Other(explain under 421 Remarks) ® ft. ? ft. /14—
4.Date Well(s)Completed:3O'alWell ID# 3 ft. 4 '3
ft. �Jv`' ��v �
5a.Well Location: ft. ft. et: } t a
a Lee ft. t< ., L.nr. .r.j -
FScility/,weer Name Facility ID#(if applicable)
Physical Address,City,and Zip ,Ir ' r
:�21:,REMARKS`. . . 1:,,,....„r ti ..-..
/team 10000909
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 O •
/�Q/fc/�L.1 (J °-a!
�� Signature erhfied Well Contractor Date
6.Is(are)the well(s): 12 manent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or (moo 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 t e same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
��ff
9.Total well depth below land surface: /03 (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@I00') construction to the following: 1
10.Static water level below top of casing: /O (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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:
(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) ! Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: /G OL
constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013