GW1-2021-01509_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) Por Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr ,4... AT ::...::::>;::;:;:.
FROM To DE$CRfPTION,
Well Contractor Name f&ft- /7a ft. G°
2670-A rL > ft. /'
NC Well Contractor Certification Number L t.c
B & K Well Drilling Inc FROM TO DIAMETER THICKNESSI MATERIAL
0 6 ft. qe ft. 6 1/4 SDR-21 PVC
Company P+ame
2C1$1t1iVERt ORI3SL`7ET aotbermalcKanki[ >'i''E:
/ _' FROM 'r0 DIAMETER 7HICKNES$ M1tATtR1AL
2.Well Construction Permitt#: !EJ
List all applicable well construction permits.+.e.UIC,Cotuuv.State.Variance.etc.l
ft. tt. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETEN SLOT$IZE THIC.KNM MATERIAL
❑Agricultural F�.deip'tial
al/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) Water Supply(Single) ft.e :::::::! ntial Water Supply(shar d)❑Industnal.Coniniercial > z::::;::
❑Irrigation ❑Wells> 100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&r11IUUNT
Nun-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
❑Monitoring ❑Rccovey ft. ft-
Injection Well: ft. ft.
oundwater Remediation
❑Aqulfer Recharge ❑Gr
:.1'}::&A3V?Bel"GA�4'�'d:ai'.Y�;fCflf.... he&b1eT'i5:�2;::.:........:::::::.:-..:. ,:::::•::::.:•..•::.:.
❑Aquifer Storage and Recovery ❑Salilliry Barrier FROt 1 TU 1 NIATF,RIAI, F,MPLAChAWNT METHOD
❑Aquifer Test ❑Stormwater Drainaee fc ft.
❑Experimental Technology ❑Subsidence Control 2 tt
❑Geothermal(Closed Loop) ❑Tracer
73Ri)rC;iiViGEOG�
FROM TO DRIPTION minr.hardn s.wirtr«k m sift etc.l
ESC
❑Geothermal(HeatinJCooling Return) ❑Other(explain under#21 RemarU- ) ft- k.
4.Date Well(s)Completed:a'/ t5 - .I Well ID# ft4;4
ft. 6 fL
,a.Well Location:
G tS p ft.
FacilitylOt�rer Namr
Facility M (if ppficable) ft. ft.
ft.
� 1 t•-1,� CAN/� (�?j`�V t�1 l�,�J ft. ,
Physical Address.City,and Zip
IS'..
a.�to --
County Patccl ldcntification No.(PIN) q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. ,-
(if u•cll ticld,one lat/lono is sufficicnt) 22.Certification:
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): nPermanent or ❑Temporary
\�Ncta
Brsignino rhCs/greet.!hereby get»/i that the,:rll(c)w2c(imrr;l<rnsrrvtred in arcbrdmu�e tvirh
7.Is this a repair to an existing well: ❑Yes or 15.4NC.tC 02C.0100 or 15.4 NCAC 01C.020n Hell Conumction Standards and rlwt a comn-
!(this rs a repair.fl/our kno n wetl.�onstnaaime information mtpin the nature of the of this record has bt rn provided to the nrll owner.
repair under§Zl remarks section or on tire back gfildsform. 23.Site diagram or additional well details:
8.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 o ly 1 GW-1 is nccdcd. [»dicatc TOTAL NUMBER of wells
(add'See Ovee in Remarks Box).You may also attach additional pagca if necessary.
drilled: >>JJ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7� 00 Submit this GW-1 within 30 days of well completion per the following:
For muhiple,cells list all deptlu if different(example.-3(a00'and?(¢)100 i
24a. For All Wells: Original form to Division of Water Resources (DVdR),
10.Static water level below top of casing:40 (fo Information Processing Unit,1617 MSC.Raleialr,NC 27699-1617
rl\ruter level is abur'e crtsing.use"+"
6 1/8 24b.For Injection Wells:Copy to DWR Underground Injection Control(IOC)
11.Borehole diameter: (in.) 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 trwtarred
FOR WATER SUPPLY WELLS ONLY: 24d For Water Weds producin¢over 100.000 GPD:Copy to DWR,CCPCUA
S Air Lift PrnnttProgtani,1611 MSC,Raleigh.NC?7699-1611
13a.Yield(gpnl) Method of test•
13b.Disinfection type:ChlOr. Tabs Amount: 1 1/2 Lbs
Form G W-)
North Carolina Department of Environmental Quality-Division of Waier Resources R.evised 6-6-2019