GW1-2021-01505_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For internal Use only:
1.Well Contractor Information:
Alfred Kiesling Sr ,4.:.1tA'R:z VES::,:>.:..
FROM TO DESCRIPTION
Well Contractor Name f
2670-A
NC Well Contractor Certification Numberr ;CA fam { ;plr:illVElt eatile'
B & K Well Drillin Inc FROM TO KkVIETER THICKNESS MATERLAL
g 0 ft. 190 tt• 61/4 in. SDR-21 PVC
Company Name
>2Gi'1�1rR Y'A'531�1(";[)R Tl)B�7k?: cethe>•maketosc��"�}
2.Well Construction Permit#: FROM TO DIAME'1'EK THICKNESS MATERIAL
List all applicable well construction permits fi.e.U1C Comity.State.Variance.ate.) fl. f6 in.
ft. ft. in.
3.Well U (check well use):
1.7 SCREEN.:
Wa Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
icultural OMunicipal/Public ft. ft. in.
❑Gcothennal(Heating/Cooling Supply) 19Residential Water Supply(single) ft. it, in.
hercial OResidential Water Supply(shared)
❑lndustnal Contn <11;s:t',ItUi3'r''aa<;>.» ;:>:;»:;:;:::;i's:;<�5:;>:; ,:;<;:,<:;<;;; :;;<:;
❑irrigation ❑Wells> 100,000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AINIOUNT
Non-Water Supply Well: 0 ft. 20 ft• Benton ite Pour
❑Monitoring ORcu:ovcry ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑(iroundwater Remedialion
1�SrIBtGvd.PkFtHf: <'
❑Aquifer Storage and Recovery: OSaliniry Barrier FROM TO MATERIAL EMPLACEMENT f1F.THOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(,Closed Loop) ❑Tracer ZORl E[1NCt U.
iittiicgall eile3steeis3friecessarvl';:.::>'::::'
FROM TO DESCRiPT1ON color rdness,soilln-k e. .o siu.etel
❑Geothermal(HeatigWCooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Complete_' � Well ID#
} t. R O ft. hado 4 5 �C1
`Sa..Well Location: l�
a. 6, f
Facility/Owner Na e l FacilityM (ifapplicable) ft. ft.
3 ft.Ll1 Llnr MOUAC r 5 a , r
t
a�� � i
ft ft"('�� a
Physical Address..City.and Zip -
TtE;1tii.1Rir5
County Parcel Identification No.(PIN) y F1\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
nrv. Y ) �sit
(ifw•ell field,one lau'long k suftieicnq 22.Certiticatilm y
17)
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary'
Brsigning this ftnm.1 herehr cerai that the,:rll(.0,vas(were)construt red in a-cordance with
❑Yes or D 1 S.-1.VCAC 01C.OlOa or 15.a tiCAC 01C.0100!Pell Construction Standards and that a cops•
7.is this a repair to an existing well:
!f this is a repair.fill out knout well canstnavinn informaiinn ar explain the nature nj the of this rrenrd has been provided m the xrll owner.
repair under#21 remarks section or on the back of this form. 23•Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction-only I GW-1 is needed. Indicate TOTAL NUMBER of w>clls (add'See ON-ce in Remarks Box).You tnay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the folkodring:
Fur multiple wells list all depths if thfferent(enampte-3(g000'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft•) Information Processing Unit,1617 MSC.Raleigh,NC 276994617
lf,ruter level is abuse casing.use'•+••
6 1/8 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IOC)
11.Borehole diameter: (�) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the county where installe t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gent) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type! Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of En,irorimcmal Quality-Division of Water Resources I:evised 6-6-2019