GW1-2021-00871_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1} Eor lntemal Use Only:
1.Well Contractor Information: p
Alfred Kiesling Sr 14:hlFLR:ZQN
_.
FROM TO DES'CRIPTION
CVe1lConhactorNarne
2670-A
NC Well Contactor Certification Number
1ra:;(i1)'63~R:Fir1$irl'f�`.farmttlt-cased�vells G1R:I:tSvF,tt' Ile > ;. ,
B & K Well Drilling Inc FROM I TO DIAMETER TMCKNESS I MATERLAL
0 ft. 61A in- SDR-23 JPVC
Company Mime
` � #&: ER:G" rrf3R:�'fIA�TCr 'ei>,rbersiateYtsed=loe ;
2.Well Construction Permit#' FROM I TO I 01AVIETER I THECKNE IMA'1'ER1 L
List all applicable weft rwu, cdon per:nits ve.UTC.Corwrv.State.Variaxcc.etc•.) ft. ft. im .
3.Well Use(check well use): ft. fL in.
Water Supply Well:
FROM TO DIAMETER 'LOT SIZE I FHEC.KNFS$ MATERIAL
OAgriculturat f7Municipal/pubiic tt. ft_ m-
OGeothermal(Neating/Cooliug Supply) Residential Water Supply(single) ft. ft. in
01ndustriallCommercial O idential Water Supply(shared) -::
Olrriaation 0 Wells> 100,000GPD FROM To KxTERLA F.IFLACENEM"TnrErao,7.&.�izoevr
Nun-Water Supply Well: 0 fL 20 ft- Bentonite Pour
0MOnitoring ORmorcrv' fr. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:fi 1t€f33GR V1- fiGif;(aT ,,. fe
DAquifer Storage and Recovery OSaliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
OGeotheimal(Closed Loop) CTracer Zh::13RTLbIIYf:3 sot ch•aa# tie�Ycalslteats3Fiietcsssry
DGeothermal(Hearin lCooling Return) OOther(explain under#21 Remarks) FROM ft. T ft.
o AE5CRIPTIo�(ceMr,hxrdnus san rack size,etc
4.Date Well(s)Completed: ? Well ID# ft. ft. r—
ld
Sa.Well Location: ft. ft. r
` ft. ft. ,
t
Facility/Owner Name ,% Facility TD*(if applicable) ft. ft. ig%j,,)rrnntk)nPrGCessingUnit
ft. DWR Section
Physical Address,City,and Zip ft, ft.
�.�17$SiYl:�ifit:'ii:;i:i;i�<v;�f?=, ; _::+-:..F:::.:2;:ii:�`*;a:�2 `i`ci•`;i;::?;� :i-',;'<ii> �ii.�f:>i�i�$;�;;>::
6t1,ya• Ljsf
County Ptirccl ldcritification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilona is wtficient) 22.Certification:
N W
6.Is(are)the weil(s): OPermanent or ❑Temporary '--Slpatf ofcenifie4 Well contmelof, Date
&r signing ihir/brm.1 herehr iv>rtifi that rhP A:rl!(sJ Av rs(were)ronstrut led in at.vrdmrre xirh
7.Is this a repair to an existing well: Oyes or *o 15A NCAC 2'C.0100 er I5A NCAC 02C.0200 rf ell Construction Standards and d4v a calm
!f this is a repair.ill our knoxn wll onnstruciinn informatimn an lair the nature nfthe t!f this trcnrd has hceu proridrd m rh,�erll owner.
repair under#21 remarks section or on Ste hack 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
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add`See Chet'irr Remarks Box).You may also attach additional pages if necessary.
drilled:4 24.SUBMITTAL INSTRUCTIONS
` .
4,Total well depth below land surface. d l J (ft.)
For multiple trelts list all depSrs ffdifjfe-1(&^ample-3(ai_00'and 2@100} Submit this GW-1 within 30 days of well completion per the following:
,At 0 24a, For All Wells: Original fors to Division of Water Resources (DWR).
10.Static water level below top of casing:`} (ft,) Information Processing Unit,1617 MSC_Raleigh-NC 27699-t617
If\cuter le,ef iy above casing.use
11.Borehole diameter:6 1/8 (in.) 24b.For Injection Wells:Copy to DWR.Underground Injection r ontrol(IUC)
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 entironmental health department of the county where in.,-tafled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producin-over l00.000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm)� Method of test: I
136.Disinfection type,Chlor. Tabs Amount: 1 112 Lbs
Forth G W-I North Carolina Department of Pm irowncntal Quality-Division of Water Resourecs Revised 6-6-201 R
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