GW1-2021-02270_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Intenial Use Only:
1.Weil Contractor Information:
Alfred Kiesling Sr
m
Well Contractor Name I-KONI TO DV.CPIPTI0X
f
2670-A
NC Well Comactor Cenification Number B & K Well Drillin Inc 119 Unit :15.0V-TER 1
g FROM TO XkVIETER THICKNESS NATERLAL
0 ft- 16 114 in- SDR-21 PVC
Company Name
2,Well Construction Permit#: 13 FROM IrU DlAmETER I THICKNESS I MAYERIA4
List all applicable wellconsmu,•lion permits ri.e.I 11C Comrev.State, in.
3.Well Use(check well use): ft_ ft. in.
:x
Water Supply Well: FROM TO DIAMETER I ,SLOT SIZE THICKNESS I MATERIAL
nAgriculturat 0M I at/Public ft' tL in.
0Gcothennal ffleatin-jCooling Supply) -�zidentaial Water Supply(single)
EfL in.
t-
OResidential Water Supply(shared)
Xz
01rdeation OW ells>100,000GPD FROM To KtTERJAL EMPLACEMENT METHOD.&.101OUNT
Non-Water Supply Well: 0 20 tt Beritonite Pour
OMonitoring ORcLovcry It. ft-
Injection Well:
OAquifer Recharge 06rouridwater Remadiation
OAquifer Storage and Recovery OSaliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
CAquifer Test OStormwater Drainace
ClExperimental Technology OSubsidence Control
CiGecithermal(Closed Loop) OTracer
Meotbenuai(Heating/Cooling Return) 00ther(explain under#21 Rem FROM To DEW. R1PTTON(-I*,r.h-d-s,­illr«k type. in vim etc.)
4.Date Well(s)C.omplefed1A.-5 ,,)- lWet[ID#
Sa.Well Location: ft. ft.
P()tJ,I d L_ ft.
Y7 �,,e L J 1:
Facility,lOwner Name* Facility M#(ifapplicable)
2o s e R n n s ct I n, D
Physical Address,City-and Zip ft. ft.
'�f,11-7 L
If
County Patel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it'well field,one la0c,agg isgufficicnt) 22.Certification:
N
X/
6.1s(are)ibewell(s): MPermanent orry tor Date
111K
Cl0 pol
(S9.4— CenirleG Well Coarrac
Br signing thi.v.t6rm.I hereFr rer�f.v that the,�-rll(sj wis(iwre;)consfi uvred in a, -ordance with
7.Is this a repair to an existing well: I5Y. M]No 15.4 NCAC 0,1C.010nor d4 NCAC 02C.n20n Mell Construction Standards and that a eq;ny
#'this is.repair.fill out known wallv nslmcfinn inforntatimn and evplair the nature q.1'rhe q(1111S MCM-d has IxCn r)'01'ided MI the Xr/1 01VnCr.
repair raider 421 remarks section or on the back of This form. i
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-I is needed. Indicate TOTAL NIA48ER of wells (add'See Over?in Remarks Bo ).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For ondriple truffy list all depiks if dif Submit this GW-1 within 30 idays of well completion per the following:
,ferent(eaample.-
10.Static water level below top of casing-40 24a. For .0 Wells. Original form to Division of Water Resources (DWR).
Information Processing Unit,1617 MSC.Raleigh.NIC 27699-1617
If'r«ter!eve[is dbo,r easier,use
it.Borehole diameter:6 1/8 (in.) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
Program,1636 MSC,Raleighr 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 pushr etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over
0 GEL)-Copy to DWR, CCPCUA
13a.Yield(gpm) Method of t,,t:Air Lift Pei mit Program,1611 MSC,Raleigh-N I C 7:9-
13b.Disinfection qw, Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of En,ironmcnTal Quality-Division of Water Rccpurccs Revised 6.6-2019