GW1-2021-03488_Well Construction - GW1_20210607

WELL C(;NSTRUC3:10N RECORD(GW-1 For Internal Use Only:
L Well Contractor Information:
Alfred Kiesling Sr
Well�'owracto,Name FROM TO I DEi;'RIPTION,
10 1�ft. its ft. 1�-
2670-A
NC Well Connacte'r Cerrification Number
Jiv VR:
B & K Well Drilling Inc FROM _l_TO_ --FDIA-METER THICKNESS I MATERL4,L
Com n Nam'! 10 ft. 61/4 in- SDR-21 JPVC
pa y
7777
2.Well Construction Permit FROM 1 1,0 1 DMMETER I THICKNESS I MATERIAL
List all applica&e"it cousnurcion Srate.fariancc.ex.) ft. I in.
.1.VVeil Use(check well use;:
x
Water Supply Well:
FROM TO DIAMETER CLOT SIZE I THICKNESS I MATERIAL
ClAgriculturat OMLinicipal/PubliL fr. R, in.
GGeothenital(ReatingiCoolitia Supply) )�Resideiifial Water Supply(single)
01ndustrialf(Contniercial GResidential Water Supply(Shared)
CirrigatiOn 0 Wei Is> 100,000 GPD FROM To I K,TERL&L I EALPLACEMENTMET11IOD&AMOUNT
Nun-Water Supply Well: 0 ft. ft- 18entonite Pour
Cklonitorii% ORrcw cry ft. ft.
Injection NVell: ft- ft.
GAquifer Recharge lGroundwater Remadialion
DAquifer Storage and Recovery 0SaIiiiiry Barrier FRun1 TV MATERIAL EMPLACENIFNTMIR.TROD
CAOuifer Test OStormwater Drainace
rt. tt-
OExperimentai Technology OSubsidence Control ft- ft.
ClGeothermal(Closed Loop) OTracer
0(jeothermal(Heating/Cooling Return) 00ther(e.Vlain under#21 RemarLq) FRO.1 TO DV;CRIPTTON'(_!T,,h­dness
ft- i ft-
i,
4.Date Well(s)Completed:I r J Well fD# t. S— :jzA I
�14tLA_5, -1
rt. ft.
Sa.Well Location:
ft. ft.
Faciliq,,'Ownerl,laine i FacjIiz<D#,1if applicable)
4:f _4_7%
j�
Physical Address,City-and Zip--��.� wNi Y 7 021
county Parcel Identification,No (PLN) Pro'-'-oS!Jg MR
4b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
ficid,one lat/long ksufficicnt) 22.Certification:
• N W
6.is(are)the well(s). nPermarient or OTemporary 1-211atf OfftrtilICL well Connactor Date
7.Is this a repair to an existing well: OYes or No 15.4.,VCAC 02C.0700 or 15.4 NC4C,12C.0200 J!'ell Cotutruetion Slandords and thii a coin,
of(his is arepair.fill our knol•n .1 td "'oi,the nature ni'the of this rocnrd has been prin ided in the krll own-r.
repair wide,?'21 remaria.,wficti or on the hack o1 rhisfiiml. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction.only I GW-1 is needed. hidicatc TOTAL N-UMBER ofwclls (acld'See(>vei'in Remarks!Box)-You may also attach additional pages ifilecest�aly.
drilled: /( 24.SUBMITTAL INSTRUCTIONS
r (ft.)
9.Total well depth below land surl ace*. I L1
For otulniqlr wells list all deptlis ffififferen,(einniple-0;,,qLM0',,n11 3(d0o') Submit this GW-I within'30 days of well completion per the following:
40 24a. For All Wells; Ori i vinal form to Division of Water Resources (DA'R),
10.Static water leeel below top ofcasing: Information Processing Uipt,1617 MSC,Raleigh.NC 27699-1617
jf�rute,level J"ab-e casing.use­" t
11.Borehole diameter: 24b.For Injection Wells.Copy to DWF_Underground Injection Control(rUC)
Program,1636 MSC,Raleigh,11,1C 2?699-1636
12.Well construction method:Air Rotary
11c.For Water Supply and 0 1e Geothermal Return Wells.Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health depaimunty where to tailed
FOR WATER SUPPLY WELLS ONLY; 24d.For Water Welts Producing over 100.00 CPO:Copy to DWR,CCPCUA
Permit 11.1611 MSC.Raleigh.NC 270-9-1611
13a.Yield(gpm, Method of test. Lift
13b.Disinfection type. Chlor. Tabs Amount. 1 1/2 Lbs
Form G W-I Nonh Carolina DQparrinctit ofFn%irownctital Quality-Division of Wmei Resourecs, Revisod"-20IX