GW1--06919_Well Construction - GW1_20241119

WELL CONSTRUCTION RECORD 1
For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14;WATERZONES -i -
FROM TO DESCRIPTION
Well Contractor Name 96 ft. AM ft. Y/' (�
2834-A /asp• /30 ft- (/ i'
NC Well Contractor Certification Number 15:OUTERCASING'(formuIR, ed )iOR-LINER(if'ap licable)7''
FROM TO D TER THICKNESS MATERIAL
Kennedy Well Drilling © ft. 45-3 ft. 6.25 , In' SDR-21 PVC -
Company Name 16 INNER CASING'OR TUBING(geothermal closed400p)r:` _ _:
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a y-O'(®/7 99 ft. ft. in.
List all applicable well permits(i.e.County,State, ariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER,r SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Muni ipal/Public
❑Geothermal(Heating/Cooling Supply) CPResidential Water Supply ft. ft. in.
(H t;/ g PP Y) PP Y(single)
t8.GROUT = ,
❑hldustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT`
❑hrigation 0 ft• 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL`PACK(if applcable)
FROM TO MATERIAL EMPLACEMENT METHOD u
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainageli
ft. ft.
❑Experimental Technology 0 Subsidence Control is
•20 DRILLING LOG.(attach'addiftoual"sheetsif necessary) '`
❑Geothermal(Closed Loop) ❑Tracer FROM TO _ DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. S- ft.
4.Date Well(s)Completed: / Well i:D# ft' /� ft" filZet ��✓�
p /� � � 1N
C n ft. .yc ft. /F�ge, .-
5a.Well Location: 76 -ft. /9/3 ft. ,�a
Cc V _
r b 9 ei.-.t_7 ft. ft. r t.1:, _.. - a J
Facility/Owner��[[ Name /+ ')'''Facility ID#(if applicable) - f 3
3/ 1•.� 5d� 6/DUB / /tL ft. ft.
NU1( 1 `7202'
ft. ft. j,
Physical Address it/yandZip (((,,, ;.21 REMARKS ' '". •, '=a,,•lr�.�.,.': r-t `'111_tl.�t `-
County /// Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W 4' / to/��a�
� Signatur f Certified Well Contract 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 ISA 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 Divo 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
S.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 forns. SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: fr,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@20V'and 2@100' construction to the following: I '
•
10.Static water level below top of casing: (D® (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: hi 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) a 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 hypocholrite Amount: /p�� well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res lurces Revised August 2013
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