GW1--06921_Well Construction - GW1_20241119

4
WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information: - —
Billy Kennedy ;1144..WA-TERZONEs .TODESCRIPTION '
Well Contractor Name /025 fL / 'fr• 3 Crl pr't
2834-A ft. H. 1 1
NC Well Contractor Certification Number :15.OUTER CASING(for multi-cased'wells)OR-LINER'(if an Haile):
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. 67 ft 6.25 'n• SDR-21 PVC
Company Name 16.INNER.CASING OR TUBING'(t eotherinal.closed-loop)
��nn^^ — 7 y'7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2L)23 OO�O�1// / ft. IL in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) .
ft. ft. in.
3.Well Use(check well use): 17.,SCREEN ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) QRKesideatial Water Supply(single) ft' ft lii.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT. s'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
• OMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation :19.?SAND/GRAVEL PACK(if applicable) .,.•.;' t;;
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
•
•
❑Experimental Technology ❑Subsidence Control 20.,DRILLING LOG(attach additional sheets if necessary) -•-
❑Geothernal(Closed Loop) ❑Tracer FROM TO DESCANTj�N(color hardness,soil/rock type,grain size,etc.)‘`.':.,'..:,.''.:1)'
'y
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) © ft. 0 ft ,�i��s ' Jt
j� , y .
4.Date Well(s)Completed:/0.3/--02 Nell ID# -1 r- ft. 02 ' _ft SQ
5a.Well Location: a.7 ft. GO ft. Sa /-d
l-acrV if) /1AcAet,z)e 6,0 fft. ft.
t. 3�3ft ��%b�:: : . .. ,
Facility/Ow er Name Facility ID#(if ficable) . .
A ft ft. 4
/3eo /`',ie5 Ai/ Koh ft ft. NU V 1 f, i0a4
Physical Ad s,City,and Zip 21 REMARKSr'; i
t� e/loll 777 020?7.72 !r,.,:,
County Parcel Identification No.(PIN) ••
L '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,.//
N W , ., 12-e P 70a/a
Signature ocertifi Well Contractor ' Date
6.Is(are)the well(s): C2i'ermanent 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 LtNi copy of this record has been provided todhe 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 form. 2 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .7 O'3 (f.) 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: j
10.Static water level below top of casing: 30 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (•m.) 24b.For Iniection Wells ONLY:i In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r®fia r )/ construction to the following: ! '
(i.e.auger,rotary,cable,direct push,etc.) /
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Clenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Wells:Also submit one copy of this fornn within 30 days of completion of
granular hypocholrite / well construction to the county health department of the county where
13b.Disinfection type: Amount: !/#Or-
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013