GW1--06915_Well Construction - GW1_20241119

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 70 ft' 7� ft- tg'drh
2834-A ft. ft. ,I .
NC Well Contractor Certification Number IS.OUTER.CASING_(for multi-cased welisj OR LINER`(if ap 1[cable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. 30 ft* 6.25 ;' In* SDR-21 PVC
Company Name 16INNERCASING:ORTUBING:(geothermalclosed.loop)`.. - .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: S�?Li ft. ft. 'in.
List all applicable well permits(i.e.Connor,State,Variance, jection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ 'pal/Public R. ft. in
Meng
❑Geothermal(Heating/Cooling Supply) isttcsidential Water Supply(single) ft. ft. In
❑Industrial/Commercial ❑Residential Water Supply(shared) PROJi TO 18.GROUT. ; , -
MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft ft
Non-Water Supply Well: 20+ Bentonite Hydrate chips in place
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:•SAND/GRAVELPACK(if applicable),, `.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METAOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑subsidence Control -`.20 DRILLING LOG(attach additional sheets if necessary):.
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain she,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft Er n- )fe
,,,j,,,t,74,1
ft. a ft.
4.Date Well(s)Completed:so �giVell.# ^� fu �txt^/ R• ldJ
5a.Well Location: �A,�Q O� ft (/V
�(' Aa a�//e ft. ft.
Facility/Owner Name Facility IDll(if applicable) it ft.
®e64Er u1C ff � °'at�� ft. ft. ;• ��VV� 1 J cUL`t
Physical Address,City,and Zip
e� OP
County Parcel lachfification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W 1od3r&ll
Signature erti led Well Contractor Date
6.Is(are)the well(s): IF ermanent or ❑Temporary
By signing this form,I hereby cernfy that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and dun a
7.Is this a repair to an existing well: ❑Yes or fio 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 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.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 forna. SUBMITTAL INSTUCTIONS ;
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-3ttt 200'and 2@100) construction to the following: ; '
10.Static water level below top of casing: I3O (ft.) Division of Water Resources,Information Processing Unit,
Ifnrder•level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (m.) 24b.For Injection 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 constr uedon method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) •57) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fOIUI within 30 days of completion of ' t
granularhypocholrite well construction to the countyhealth department of the county where �' •
13b..Dis-infection type: Amount: Per
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013