GW1-2021-02282_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-l) For Internal Use only-:
).Well Contractor Information:
Alfred Kiesling Sr
ZO.
;t s FROM To DESC.RtPTtO�
Well Contractor Name ' I t
2 V 70^/t 11. / ft. j'YJ 4V
`�
NC Well Contractor Certification Number ( n
B & K Well Drilling inc ,t t., W',3t'3 iltriCfxoiS:t1 )111i# FROP(atllCE12. TO/ , lePm METdER3e11s N THICKNESS eMAERLAL
Company Name 3 tl ti%C..�I(1n Q ft ij(, ft. 6 1/4 In SDR 21 PVC
xrk]NNER fg5ll�CrARi�'I)BEsTG syrhernfat:cCaisett hw} : ,
2.Well Construction Permit#1:Fµ W'4 i FROM I To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction A rmits r.e.L11C.Cotucty.State,Variance,etc.} _ft. I ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM I TO I DIAMETER SLOTSIZE THICKNESS I MATCRIAL
OAgricultural OMunicipalfPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft fL in
OlndustriaKonuuercial OResidential Water Supply(shared) 1 _t;1it]II I
❑Irrigation' OWelis>1000OOGPD FROM TO MATERIAL. HMPLACintr TMMOD&.AMAUNT
Non-Water Supply Well: 0 ft. 20 ft. BefitOfilte Pour
Oi$onitoring ORccovery ft. ft.
Injection Well:
ft fr
OAquifer Recharge ❑Groundwater Remediation
39::&;ilr�ti�lL3*r�l..i?a�jKGf _liciitile) ..: ?,
❑Aquifer Storage and Recovery OSaliuiry Barrier FROM TO h14TF,RIAI. EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer <: �1#)#7I,L1fi7fi�R{l�attaelaii�(iiiriliT:st #: i�essstr?`> ..
❑Geothermal("HeatinJCooling Return) ❑Other(explain under#21 Remarks) FROM TO ft. DEs.nrP ta. color.hardness soNroek .t„sRG e..m
4.Date Well(s)Completed: VITs t�1 l Well ID# o ft. t
5a.Well Location: ft, �A r 1 ft.
j ft, ft.
FacifitytOtvner Name Facility f #017applicable)
ft, ft.
r� m Vmnan �
Physical Address,City.and Zip ft. ft.
County Parcct Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latllona is sufficient) 22.Certification-
N
Is ar thew 1 P rmanen T ran' Sigenat of Certified Well Contractor: Da
6 ( e) a 1(s)- CI e t or O ergo
kysigning this farm.I here,'i,rerrih:thar the:rll(.sl Iran(were)construrred in ac-ordmx•r nirh
7.Is this a repair to an existing well: ❑Yes or InNo 1 N NCAC 02C.0100 ar 15A NCAC 02C'.0200 il'eli Construction Standards and that a com
If this is a repair.ell our known well construction inforrnotinn and explain the nature of the of this record has been provided to rh,,'nrll owner.
repair under#21 remar ks section or on the back of this farm.
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 info
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 O S (ft) Submit this GW-1 within 30 days of well completion per the following:
For andriple,cells list all rlepilrs if different(rxarnpte.-3(a1200`tunut 2@?700)
l0.Static water level below top of casing An (it.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.St tic is abuse casing, w op Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
ff 11.Borehole diameter:6 1/8 24b.For Injection Wells:Copy,to DWR:Underground Injection Control(IUC)
(in-) 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,terry.cable,direct push,ate.) county environmental health department of the county inhere installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciip over 100,000 GPD:Copy to DWR,CCPCUA
r� AIr Lift
Permit Program,1611 MSC.Raleigh.NC 27699-16t t
13a.Yield(gpm) L Method of test:
Tabs r
13b.Disinfection type: Chlor. Amount: 1 1/2 Lbs
Porn GW-I North Carolina Department of EIn ironntcntal Quality-Division of Water Resources Revised 6-6-201 R