GW1-2021-01553_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW- For Internal Use Only:
1.Well Contractor Information:
:T`;31SFY _5::::iC3ii;:;::;.i:;;:i,< i:::
Alfred Kieshng Sr FROM TO DESCRIMON'
Well Contractor Name �I r^ft. 7 ft.
2670-A iAAR X 9 2021 6 CJft. ` ft.
NC Well Crnttractor Certification Number 15YNI FFitGll9#�iGi#e miittpca9eii: Ts'FJQ: NFA eal3le i'ii i;:i::4«>:;:`:;`:.:>
B & K Well Drilling lilfMnation Processing Unit FROM TO DLOIETER THICKNESS !1MATERL+L
E)WR �G�l13n 0 ft. ft- 61/4 in- SDR-21 PVC
Company Name J (u�I!T1VEI7.I YSi :l t F1I3L G 9t#tErIDike[osRtB 3
T �`1 �\e• �f� FROM DIAyierER THICKNESS MATERIAL
2.Well Construction Permit#:ire ^rV ll fL ft. in.
List all applicable well construction permits i.e.UK'.Cwvlty.State.Variance.etc./
ft. ff. in.
3.Well Use(check well use):
X.
Water Supply Well: FROM TO DIAMETER $LOT SIZE THICKNESS !1LATERIAL
❑Agricultural ❑ cipal/Public n. ft in•
❑Geothermal(HeatinJCooling Supply) Residential Water Supply(single) ft. ft in•
❑Industnal?Conunercial ❑Residential Water Supply(shar ) t ::;>:::
❑irrigation ❑Wells>100,000GPD FROM TO bL%TERIAL EDIPLACE�r-r METHOD
&r1AfOUNT
Non-Water Supply Well: 0 fL 20 ft Bentonite Pour
❑Monitoring ❑Rococery ft. ft.
Injection VV'ell: ft. ft.
dwater Ramadiation -<.;; ..: _:. .:.:..:::.:::.::: ..:..
OAqurfer Recharge ❑Crrouu ?::;>:::;;::;;:<
iLliSi'ltie4' L::1P>tF3C'klf bka':,;;<ii;?.._.......,.i2»(ii�`:::i it:::;::':;i;?
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO NIATERIAL EMPLACE KAT METHOD
❑Aquifer Test ❑Stormw'ater Drainaee R fL ft.ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
FROM
TO DESC'.RTPTfO�(coMr.hardness,soiVteek In yizr:ete.l
❑Geothermal(HeatinJCooling�Ryeturn) j ❑Other(explain under#21 Remarks) k2kft. R.
4.Date Well(s)Completed -d`�7_)1 Well ID# (� ft• ft. �• 9
ft. ft.
5a.Well Location:
ft,
P) C',r k It -5 a1 tt_ ft.. ft. _
Facilit,/Ocvner Name Facility ID',(if applicable)
ft.
` b / ft
�` to
ft. R.
Physical Address.City,and Zip .. ..............:.... ..........:...:r; ....•::::::::;;:o-;::::.::;;:.:::.::.::. :•::�>::>:��:>:tiS:::::
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if u-cil ticld,one Iatilong is sufticicnt) 22.Certification:
N W � 7- (91
Signature of Certified Well Contractor Date
6.Is(are)thewell(s): Permanent or ❑Temporary
By signing this torn.)hereby rer•h!that the,vel/(s)was Over(V ronstrutred in arcorannee with
7.Is this a repair to an existing well; ❑Yes or 15.4:NCAC 02C.0100 or d4 NC,4C 01C.0100 Well Coactr u lion Standards and that a copy
(J this is a repair.Tll out knor-n well construction information air Ptplain the nature o(rhe q(this record has been prat ided in rho-ell our rr.repair under 421 remarks section or on the back ofthisform. 23.Site diagram or additional well details-
R.For Geoprobe/DlY) or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
(add'See Over'in Remarks Box).You may also attach additional pagea if necessary.
construction only i GW-1 is needed. indicate TOTAL NUMBER of w,clls
drilled: ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 `��'/� 00 Submit this GW-1 within 30 days of well completion per the following:
For andriple rrells list all deptkr ijd ffir ent(erample-3(a200'and 2@1001
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
I o.Static water level below top of casing: (ft-) lnforr ation Processing Unit,1617 MSC.RaleiJr,NC 27699-1617
if order level h•vbare eitsing.use"+"
6 1/8 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter. (0•) 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 Installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producin¢over 100.000 GPD:Copy to DV"K,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh-NC 27699-1611
13a.Yield(gpm) _ Method of test. .I
13b.Disinfection type; Cr1IOr. Tabs Amount: 1 I/2 LbS
Form GW-1
North Carolina Depanmcnt of En,iroamcntal Quality-Division of Water Resources R cvised 6-b-301✓t