GW1-2021-02283_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
e FROM TO DESCRIPTION
Well Contractor Name w r+ r ft. ✓t% n
1� ,, s
- 2670-A ��°�
12021 fL ft. /�✓1F'
' NC Well Contractor Certification Number �yd A� 2 _61P17 GAS3NG£er�inal6-cayel jcelis kIR 1itN sable :..
B & K Well Drilling Inc tH FROM TO DIAMETER THICKNESS MATERUL
�ir1�Ullt
liiiyS9 i� �t�,• 0 ft t{/ ft. 6 1/4 1° SDR 21 PVC
Company Name jC"t�OCl;,a
,„.., ^t 2&::3 �•ECGt#S1N+C?UfF�'F)SL`7G cuCheimatetiisedloo).
2.Well Construction Permit#: �� 1 �lJ `7 dsL. FROM 't'o 1 DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits fi.e.U1C:Cotuay.State.F arionce•.etc.) ft. ft.
3.Well Use(check well use): ft. rt.
Water Supply 1 Well. FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
CAgricultural OMunicipal/Public ft. fL
CGeothennal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft fis.
ClndustriallCanutierdat OResidential Water Supply{shared)
0Irrigation OWells>100000GPD FROM To M:ITERML EMPLACEMENTMETHUD&.i.MOUNT
Nun-Water Supply Well: 0 ft. 20 ft- Bentonjte Pour
0monitoring ORc occry ft. ft.
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Rentediation
OAquifer Storage and Recovery OSaiiniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
CAquifer Test OStormwater Drainaee ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 2>}<gRI1 II3tlfxi rtttaeiatEiviialEs3sitii sex+sry .:`':::: <.;<;
❑Geothermal(Heatine/Coolina Return) 00ther(explain Under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillmis type grain size.etc.)
R. ft. �
4.Date Well(s)Completed:YIla IAA Well lD#
5a.Well Location: R. -
itari� R wtSQr+,.��0� ttJJt✓1
Facility/Ow'ner Name
�/ n Facility M#(if applicable)
ft' ft'
Is-A 1 �«'t+r a t/tvt L c r.-k 1,11 ft. fu
Physical Address.City.and Zip ft. ft.
County Parcel Identification No.(PW) -
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W 6ii:r� ",
���
6.1 are the wells): OPermanent or OTem orary Siena ute o€Certifier ell contra r Dat
s{ ) O N
Br signing this form.I herehr•ref qft that the,:rtt(.ry,vas(were)constructed in ac:ordmwe with
7.is this a repair to an existing well- OYes or GNo 15A.NCAC 02C.0700 or 15.4 NCAC 02C.0200 h ell Construction Standards and drat a copy
I(this is a repair.fill out known well consinwiion h1torrnatinn and explain the nature nt'rhe of this record has born provided to chi I•xrll owner.
repair under 421 remarks section or on the back ofrhis farm.
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 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: y-e).5, -(ft.) Submit this GW-1 within 30 days of well completion per the following:
For mulriple+cells list all depiln'if different(,trample-3(a1200'and:@!1001
24a. For All Wells: Original Morn to Division of Water Resources ('DWR),
10.Static water level below top of casing:40 (ft') Information Processing Unit,160 MSC.Raleigh.NC 27699-1617
, lJlruterlecrf iv above casing,use"+"
11.Borehole diameter �/$ {in.) 24b.For Injection Wells:Copy to DWR,UndertTound Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rota'r•1•��
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary.cable,direct push,etc.) county emironmental health department of the county-A sere installed
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FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing over 100,0011 GPD:Copy to DN q,CCPCUA
Air Lift leigh.NC37699-161T
�1 Perntit Program,1611 MSC,Raleigh.
13a.Yield(gpm) /C.- Method of test:
13b.Disinfection type:Chlor.Tabs Amount: 1 1/2 Lbs
i
Form G W-I North Carolina Department of En,'ironlncnral Quality-Division of Water Rcw%!i cs Revised 6-6-2018