GW1--06947_Well Construction - GW1_20241118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14 WATER ZONES - -:- . . °. - _FROM TO DESCRIPTION
Well Contractor Name /fd�ft. ittr
ft. //}l/A
2834-A /IJ ft. ft. [•
NC Well Contractor Certification Number
i-,15'OUTER CASING(for multi-cased Wells)OR'LINER(if np.licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a ft. y,,I ft- 6.25 in. SDR-21 PVC
Company Name 16.INNER_CASMG OR TUBING(geothermal closed-loop)_' „
&AA p-r�/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t' L0 1 ft. ft. ' in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�Mu//nicipal/Public R ft in.
❑Geothermal(Heating/Cooling Supply) L�PResidential Water Supply(single) ft ft In.
❑Industrial/Commercial ❑Residential Water Supply(shared)
GROUT '' -.;,
FROM18: TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft. /0
bass
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK(if applicable) %
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEI1fENTbiETHOD
ft. n I
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control '20.DRILLING LOG(attach additional sheets if necessary)`-
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft- pC ft- dIr f
�,^ a, ft. ft. /oise fI
4.Date Well(s)Completed:e0—�it—Olt/Well m# � I�FIGJ�
isi,ti
5a.Well Location: /`� ft. �:Jr 0
Alt l D /c ft. fl3 ft. d i3O
,P , ihc,icre 4D ft. ft.
Facility/Owner Name Facility ID#(if tipp ble) P_
Q y ft. ft. . '£ :� 3
/6./ /`mace �� ei ft. ft. y. ...,
rt
Physical Address, and Zip N n V Y .S Z 0 24,
�iWL��7` '21::REMARKS--;. - .
GG .2® U�•
County Parcel Identification o.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W � �Id�t /0-e"a ti
���� Sigma f Certified Well Contracto Date
• 6.Is(are)the well(s): ElPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�_� with 1SANCAC 02C.0100 or 15ANCACIO2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Leo 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 form. SUBMITTAL INSTUCTIONS
i.
9.Total well depth below land surface: ,9 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@200'and 2@100' construction to the following:
10.Static water level below top of casing: iO (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.) 246.For Infection 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,ter,Raleigh,NC 27699-1636
13a.Yield(gpm) fe Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fond.within 30 days of completion of
granular hypocholrite �1 well construction to the county health department of the county where
13b.Disinfection type: Amount: �oCQ '
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Rell ounces Revised August 2013