GW1-2021-01510_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
RECEIVED
Alfred Kiesling Sr 14.:..S.AIIEFFZUNCsS
Well Contractor Name g L MAR X n ^LOA1 FROM TO DESCRIPTION
PL tt Q fi
2670-A G S 'e
ormation Processing Unit 366 3Gs " OG
NC Well Contractor Certification Numbt DWR celOn lei:<R31ERGi NG.far.. iase44i1 s:OR*0rgFA t hea9le
B & K Well Drilling Inc YYr� FROM TO DLACNIETER THICKNESS MATERLaL
0 ft. (�Z ft. 6 1/4 In SDR 21 PVC
Company Name
kC:3IVIVER`0YSIKG;(0K"' -e3 chY}rermalctosed;
2.Well Construction Permit# FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well Construction permits(i.e.UIC.Cow+rv.State.Variance.etc.) t•
ft. Ct.3.Well Use(check well use): in.
Wgrer Supply Well: FROM TO DIAMETER SLOT SIZE TNIC.KNE$$ MATERIAL
Q/Agricultural ❑Municipal/Public 40ft
ft. in.
❑Geothermal(Heating/Cooling Supply) TIResidential Water Supply(single) re in.
(shared)
:::::::::;:;:❑Industnal/Conutrercial ❑Residential Water Supply( ) : :; : : »:>>>�❑Irrigation ❑Wells> 100,000 GPD W.TERIAL EhIPLACEMENThIETHOD&ADIOUNT
Nun-Water Supply Well: ft- Bentonite Pour
❑Monitoring ORccoecy It. ft.
Injection Well: it• ft.
❑Aquifer Recharge 06roundwaterRemediation j '.SAliBl ttavly[PkEleflf "!feeble
❑Aquifer Storage and Recovery OSaliniry Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainace ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 7r}= RiLLiIY #OG sttactradtiiunal iElects itntaessar�
FROM TO DESCRIPTIO for hardness,soil/o k e. m me,etc 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#Z 1 Remarks) ft. R.
f
4.Date Well(s)Completed:'19 21.1 Well ID# ft. ft. YYA
ft.
Sa.Well Location: �y
ills I g 1 ZL-C_ ft.
Facility/OwnerMame Facilitvi #(ifap li ble) ft.
Ph sicaI Address,City,and Zip
c i- _' ft. ft.
�a Q+�to c/
�—
County Parcel Identification No.(PIN)
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong k sufficient) 22.Certification:
N W
6.Is(are)the well(s): ❑Permanent or ❑Temporary
Signature ofCertitied Well Contractor Date
Brsq!ning this farm.!hereby rerri/i that the nrll(.d was(wrrr)constructed in arv&dance with'
7.is this a repair to an existing well: ❑Yes or No LN.VC4C 02C.010n or ls.a ATCAC 02C.0200 Bell Comtrvction Standards and Thal a Calm
1f this is a repair.fll our knoHn well<•nnrtn,clian injonnatimn n d explain the nature of the �f this record has been proridrd to the erl/owner.
repair raider#21 remarks section or on the back of this form. 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
constructio> ly I GW-i is needed. indicate TOTAL NUMBER of wells (add'See Over,in Remarks Box).You may also attach additional page.,if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' —� (f') Submit this GW-1 within 30 days of well completion per the following:
For multiple n•ells list all depths ifdifferent(example-3(a1_700 and 2@g001
24a. For Ail Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top areas 40 (ft•) Information Processing Unit,1617 MSC.Ralei=b,NC 27699-1617
If,curer level is above easing.we"+••
11.Borehole diameter 6 1/8 (in.) 24b.For Infection Wells:Copy to DWI_Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r 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 Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodncin>:over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) Method of test:
_75- Air Lift Pe1Tnrt Program,16t 1 MSC,Raleigh.NC 27699 161 I
13b.Disinfection type: Chlor, Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Ern ironmcntal Quality-Division of Water Resources Revised 6-6-2019