GW1-2021-03486_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GR'-1} For interlel Use Qnly:
1.Well Contractor Information: f
Alfred Kiesling Sr
FRO ( TO DESC.UFPTION
Well Contractor Name ft- tt. f fl tLj002f J� e�2670-A 1(��rL t y (j •1 �7u a
NC Well Contractor Certification Number -:: . .._...f.. ..:... .. ... ..:. . .. .. .... .
17-�,1L"fEibGiLS�Nir:Formultx'ciised:. OR'F�?VEX'flt , .cable :. '
B & K Well DrillingInc FROM TO MALMETER' THICKNESS MATMAL
() ft. to f( ft. 6'1/4 in ISDR-21 1PVG �
CompemyNaare r/ { / } 16;11134£R`C S 4G>011 18 eo[berituatctosed=ioe} .
Z.Well Construction Permit k: }KOhI 1'O UTANt'!'LK 7'HICKNES$ MATERIAL
icrr nil applicable w 41 co_ rtrou prr.r--ru.+.<•.L%fG'.G'o+u+(v.S:nrr.Y'arlan>c.em j fit. fL in.
3.Well Use(check well use): rL fL in. l
Water Su ! Well: `
PP Y FKOfii TO OrANIETEN CLOT SIZE THI(KNfCC ttATfRtAL
❑Ag*icultu:al OMunicipaVPublic ft, tL in.
OGcothermal(HeatinJCoolm_-Supply) M<esidentia)Rater Supply(single) ft. ft in.
OlndustnaVContmercial OResidontia)Water Supply(shared)
Oirrization 0 Wells> 100,000GPD FROM TO MtZERZhL EAIPLACEtitEKTA7ETNOD&.ANIoUNT
Non-Water Supply Well: 0 20 f`• Bentonite POUT
❑�+lonitoritw_ ORc,:ovcry' fs- fr-
Injection Well:
ft. ft.
OAquifer Recharge OGroundwater Re_rtiediation
r:'L9:S„4!PiflJt>>fifidY"�1:i�ltr#C7if•:::. t;1e7::> ... .. ,.:.� :.:. ..'. .:: .:. ..
OAquifer Storage and Recovery OSaliniy Barrier FROM TO ht.ATERIAL EINPt_ACFAIEN":MF.THOn
❑Aquifer Test OStormwater Draifiaee fit, tt.
❑Experimental Technology "Subsidence Control
CGeothermai(Closed Loop) GTracer
OGeothermai(Heating/Cooling Retum) OOLher(explain under#21 Remarks) FROW To DEs TPTrO\heater.hardne4z oiUrocic e, gin aiza etc.!
ff
0 f y,
i f ti
4.Date Well(s)Completed: Well fD fit. �J ft. /
Sa.Well Location: rt. J ft.
Fatility;Ctwrer Name Facility TM (ifapplicable; ft. €t.
JJ f J ft. ft.
F+f�'� � f`(✓•GY�t tA.•wtn �S C fl d)YdZt?Y� � --
Physical Address,City.and Zip 9 ft. ( ft. i 1 7
County P 'celldentificationNo.(PIN) �6 vilC 't`'{'OCf;USlfii �}Tll
a:
[Tv 1%Sz"� -Li
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-cli ficid.ant lavlong is suf icicnt) 22.Certification:
6.ts(are)the well(s): 'OPermanent or C)Temporars rgazt •of Ctttihtd Well Contractor Da
Brsigrir�thitlornr.l herehr i rrtiJi trot the >rll(s1:<rrc(tvrrrJ r pnsnucred in arcordanre iritlr
?.Fs this a repair to an existing well: Oyes or JNo is•4:,VC4C 02C.0700 or 15.4 A%C,4C 02C A201)bell Conttr-uation Standards and dual a cols;
f rhis is a repo i+t fill our 1no.n whit rnnsira t:an minnnolinn and erplabn the nature no.rfio ofthis record has beer pronded ro rh'*vrll ouwrr_
repoi,under Y"2!rerror ks section or on the back ofrhr's.fern:.
23.Sire diagram or additional well details:
9,For GeoproWDPT or Closed-Loop Geothermal Wells hating the same You may use the back of this page to provide additional well construction info
construction.only 1 GW 1 is needed. lrrdicatc TOTAL NUMBER of wells (add'See Oeee in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9-Total well depth below land surface: hT 5 (R 1 Submit this GW-1 within 30 days of well completion per the following:
For n uldple+tells list<if!<lepilu'.if'diffrrrnt{trnmplr.-3(atc00'anet?(du 0o1
24a. For -A!t Wells: Original form to Division of Water Resources (DWR),
10.Static water letet below top of casino.:40 {fit.) information Processing Unit,1617,MSC.Raleiub.NC 27699-1 6 1 7
i f eater lour/i,<:rha+r hosing,uxr"' �
11.Borehole diameter 6 1�$ (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Prof-tam.,1636 MSC,Raleigh,NC,276 99-1 636
12.Well construction method: '
Air Rotary
24c.For Water Supply Ind 0 en-Loop Geothermal Return Wells:Cagy to the
(i.e.aueer,rotary.cable,direct push.etc.) county environmental health dPpattment of the county where in.-Wled
FOR WATER SLTPLY WELLS ONLY: 24d.For Water Welts Producing over 100.000 GP U:Copy to DWR,CCPCUr
Air Lift Permit Program,1611 MSC,Raleigh.NC 27694-161 t
13a.Yield(.pm) -J~>� Method of test: 1,
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lb
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Fonn'GW-I North Carolina Department of Enxironmcmal Quality•Division of Wd ucr Rc�ourccs Revised n fi-_01
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