GW1-2021-00939_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
FRONT TO DESCRIPTION
CVellContractorName 7.# ft. +J �%
2670-A V �-�A
NCWcllConrcactrnCertificationNumber 33.OIfE):RGNE:'({ot..misC .'wei)s.4fRt1�FR'
B & K Well Drilling Inc FROM1I TO D14vIETER THICKNESS MATERLAL
p ft a ft. 6 114 ' to SDR 21 PVC
Company Name
�.�1,`�
2.Well Construction Permit#• FROM I 'ro DiAylr.rER I THICKNESS MATERIAL.
List all applicable well eowrrurcioa perneirs(i.e.U1C,C:orunv.Stott. Zaric"Ce.etc.) ft. I in.
3.Well Use(check well use); ff. ft. in.
<:CI:7 E`f:;�<::.::2s;:<::as: i;>:j::::i':ii`:ii.,;i:<::>iasi%;.6s it"• asi: ':i+:::'::;:i2Z::zi:>i:?<.,i
Water Supply Well: _ ,. ...:.
FROM I TO I DIAMETER I SLOTSIZE I THICKNESS MATERIAL
OAgriculttiral OMunicipal/Public ft. fL in-
ft*
(HeatinayCooling Supply) J Residential Water Supply(single) ft. ft ia_
❑lndustrialiConunercial OResidential Water Supply(Shared) ;1....... .... .... :::::: ::::::::.: o:::»:>..::;:-: ::;:;;;:
Olrrioation OWells>100,000GPD FRONI TO MATERLAL EMPLACEMENTMETHOD.iA1lOUNT
Non-Water Supply Well: 0 ft 20 ft" Bentonite POUT
oMonitonng ORc ovcry ft. ft.
Injection Well:
ft. ft.
OA uifer Recharge OCrouudwater Remadta o n
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To vl.>TF,RIAL EMPL..CF,E>'<St FNT MFTH00
CAquifer Test OStormwater Drainaee it. ft.
OExperimental Technology OSubsidence Control
[]Geothermal(Closed Loop) OTracer ?0 3#E --NG- :attnctrat[rl+fitv.....
OGeothermal MeatinJCoolina Return) OQther(explain under#21 Remarks) FROM To DESCRIPTION(rotwhardness soillrock sin size.eml
ft. fA
t
4.Date Well(s)Completed:3`�•L� Well ID# ft. ft.
Sa.Well Location: 6-5ft. ?a 5' ft. � � G /• ite
Facilty/OnTerName Facility M#(if applicable) ft-
4-1
Physical Address.City,and Zip e}1 —� eer l ��C� 6-1d ft_ ft.
r(
c1 3 __
County Parcel Identification No.(PIN)
ion r1 r rode&51r1f
tinit-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; -
(if well field,one latliono is sutlieicnt) 22.Certification:
6_is(are)the well(s): nPermanent or []Temporarysign�&ofGetti&6 Well Contractor: Date
At-signingrhtr 1orm.1 herel a reno:that the,:ell(.t1 icac(were)constructed iii ae,•ardance ivith
7.is this a repair to an existing well: OYes or ,\ No 15,4 NCaC NC.O100 ar 15.4 1JC.tC n2C.1I100 1te11 Construction Standards and fhar a copy
11'rhis Lr a repair,fill out kno'n well annrtrucrion informotwn and explain the nor—e of the of this record has brew provided to the Ertl oimcr.
repair trader#_1 Tema,-ks section or on the hack ofthis,fnrnt. i
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 constuction info
construction_only I GW-i is needed. Indicate TOTAL NUMBER of%•ells (add'See Chet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9_Total well depth below land surface: (ft)
For multi le+culls list all de i/u i di,etern tram le-;tu_00'and 2@100) Submit this GW-I within 30 days of well completion per the following:
P P f .1f (- P,t t�(.
10.Static water level below top of casing:40 (ft) 24a. For Alt Wells: Original form to Division of Water Resources (DWR),
1(+cuter/curl is nhw e cas;n&we"+" Information Processing Unit,1617 MSC.Ralei!h_NC 27699-1617
11.Borehole diameter:6 118 24b-For Injection Wells:Copy,to DWR.Underground Iniection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27694-1636
12.Well construction method:Air Rotary
24c.For Water Supply and O n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push.etc.) county ens ironmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producini?over 100,000 GPD:Copy to DWR,CCPCt1A
}�13a.Yield(gptu) Method of test:.
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1 61 1
�(J
13b.Disinfection Chlor. Tabs Amount: 1 1/2 Lbs
type .t
Form G W-I North Carolina Department of En,ironmontal Quality-Division of Water Rmourdcs Revised 6-6-301k