GW1--06924_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
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Billy Kennedy FROM TO DESCRIPTION - -
Well Contractor Name gr.t.
2834-A , 7 ft. Aft. eirr 3 �
1S..'OUTER CASING for:multi-c 'wells OR LINER(if Usable) '
NC Well Contractor Certification Number � ( ) ( p
FROM TO DIAMETER THICKNESS MATERIAL
KennedyWell Drillinglt. ft in.
77 6.25 , SDR-21 PVC
Company Name 1 cINNER.CASINGORTUBING.(geotheraial'closed-loop):: fl..:
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: � ft. ft. i in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. ill-
3.Well Use(check well use): 17.SCREEN " "
Water Supply Well: FROM TO. DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. In.
❑Ind strial/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:❑Monitoring ❑Recovery ft. ft. /0 he.1...0
Injection Well: ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. 1
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
'20.DRILLING LOG(attach additional streets if necessary)'`=
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color hardness,soWrock type,Grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. g" ft. 0 .0.1
4.Date Well(s)Completed:/Q c I a�Well ID# ft `"'r / s
Sa.Well Location: 12 2 ft. �//
70 ft. ��G`L
/� ft. ft. '
G1'-Vie/ 01�p_`��If'/ ft ft. I(._ i.r. ° - ,
Facility/O ner Nate Facility ID#(if applicable) ft. ft. 1e `
3.5-g'" ailtlif ,s s lbky ft ft NO 1 9 2024
Physical Addres C' and Zip »21.REMARKS—:'_":-0-.. , - ` Y ', _ ,, F;
CC„ /fiJi-, k7tJ S'c! `-'�1/ f e,...,
.' ;r j
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi ation: .
(if well field,one lat/long is sufficient)
N W /d' �/ i(
Signs Certified Well Contractor Date
6.Is(are)the well(s): [ 11e'manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�_/ with 1SANCAC 02C.0100 or 15A NCAC:02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l2No 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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ifa 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-3Qa 200'andd2(§100) construction to the following:
10.Static water level below top of casing: J 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
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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: i
(i.e.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
13b.Disinfection type: granular hypocholrite Amount 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 Resources Revised August 2013
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