GW1-2021-03497_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD{GW--1 For intemal Use niy:
1,Well Contractor Information:
Alfred Kiesling Sr 14;aS'AYt:ZU1VE5,..i: .
FROM TO DESCRIPTION
Well Contractor Name ft. O ft. Rl f� r
2670-A /`i°
ft
NC Well Contractor Certification Number 15(itl IEIi:CASLNt :f6i im�i ca led welts;:G? i t1H)vit eatile
B & K Well Drilling Inc FROM TO DLkYl.ETER THICKNESS MATERLAL
SDR 21 PVC
Company Name -
',t n err J
2,Well Construction Permit#: ►T W J I 0 16 Q {O FROM ro1 DIAMETER I THICKNESS I MATERIAL
Cur all applicable+vest cw"micdoe perrnits i.e.1_11C.Catusty,State.Nzriancc.etc.) ft. ft. io.
3.Well Use(check well use): ft. ft. in.
NX:iWater Supply Well: f f;SGitEEfii:;: . .....:
: _
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
OAgricultural OMunicipat/Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) eesidential Water Supply(single) ft. ft. in.
Olndustrial/Conuuercial ❑Residential Water Supply(shared)
Olrrioation OWells> 100,000GPD FROM TO MATERIAL EnIPLACEMENTMETHOD&.OfOUNT
Nun-Water Supply well: 0 t` 20 f` Bentonite Pour
OMonitoring ❑Rccovcry
Injection Well:
OAquifer Recharge OCiroundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL BNI PLACEMENT METHOD
OAquifer Test ❑Stormw'ater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
OGeatherstal(Closed Loop) OTncer SO-Ok1w#!1GL4G:aitachadd+iin�sl3 ef�:IF:t cessaix....,
FROM TO DESCRIP ON mtor.hardness,"fl/ ek in size emi
OGeothermai(Heatin&Cooling Return) OOther(explain under#21 Remarks) ft. '.2 ft. btG
4.Date Well(s)Completed: �- Well ID# 0 ft.ft.
ft. �jt llll/ G3I
5a.Well Location: ft. �✓�- ft.
Facili
ty/Owner Name Facility in#(ifapplicable) ft. ft.
Physical Address.City.and ZipNJ
21 RES2aR
County Parcel Identification No.(PIN) Unit
, orr,^,a���n �ra�ESsl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifneli ticld,one lat'long is sutlicicm) 22.Certification: v
6.Is(are)thewell(s): ()Permanent or OTemporarr ignat eofCemfiedwellContractor !f Date.
By signing this lorm.1 herehr ver4hf that the t:ril(sl was(were)constr-uc-ted in arcordance+Yrth
7.Is this a repair to an existing well: OYes or LtNo 15A NCAC 03C.0101)or 114 NCAC 02C A2on bell Construction Standards and that a copy
1%this is a repairs ill our knoHn well rnnsinie iorr inforrnatinu and explain the natut-e n%the oftltis record has beenpr-aridrd to the xrll owner.
repair under 421 remarks section or on the hack ofthis farm. 23.Site diagram or additional well details:
8.For GeoprobeiDPT 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 wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J.25
Far rolls tut aft depths ifclifferent(ea-ample-3(g1200'and 2Cgtloo} Submit this GW-t within 30 days of well completion per the following:
mutriple+
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1'617 MSC.Raleigh.NC 27699-1617
Jf,ruter tewrl ix rrbu,e easing.uxe"+"
11.Borehole diameter ra 1�� (in.) 24b.For Iniection Wells:Copy to DWR,Underground Iniection Control(IUC)
Pro-ram,1636 MSC,Raleigh,iNC 27699-1636
12.Well construction method-,Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return V-1ells: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 Welts producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.Yield(gpin) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611-
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 L bs
i
Form GW-I North Carolina Department of En,ironmcntal Quality-Division of Water Resources Revised fr6-2019