GW1-2021-01599_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
''i' .•'CSiis:ii;itiii::iii;i:::
Alfred Kiesling Sr 4.� -� Zfl1
FROM TO DEtGRFPTIO�
Well Contractor Name
2670-A �" 3` a t.
ft. ft.
NC Well Ctn,nactor Certification Number
fedvuitltl L'14CiI'::, OR'31NFt2
B & K Well Drilling Inc FROi%l TO 1}1.AVETER THICKNESS MATERLAL
0 n C$ fu 6 1/4 in SDR 21 PVC..
Company Name
4G::I1vN£Dba~aSIIe1G i� G:'eagtezmel teased-•.
�` ) (^} FROM 70 InAMETER THICKNESS MATERIAL2.Well Construction Permit#: C� -"I ) ! 55_",`
t isr all applicable well construrCion permit r.e.&C.Cotow.State.kariance.die.) €t. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: ......
PP Y FROM .. TO DIAMETER slot SIZE.. THiCKNES,S MST£RIAL
D3Agrie utttital DM icipaUPubtic ft. tt in.
ClGeothetmal(Heating/Cooling Supply) esidential Water Supply(Single) ft. tit. in.
Supply
0lndustnal.Conmzeresal ORessdanDai Water (shared)
Oirri ation OWells>100,OOOGPD FROM TV MATERL&L EAtpLACE NT niETftVD.&.4;tOUMT
Nun-Water Supply Well: 0 it 20 ic• Seiltonite Pour
Oklonitoring ORccovcry ft. ft.
Injection ir4•etl: ft. ft.
OA uifer Recharge DGrouudwater Remediation -
.'3+�:&aall�Cit�Y�..i*+I(•.�`f�••:•::..r. to .. .. .
DAquifer Storage and Recovery DSalinky Barrier FROM TO MATERIAL F.MPL.ACEWNT METHOD
OAquifer Test ! OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control fe. ft.
OGeothermal(Closed Loop) OTracer
FROM TO DESCRIPTION tuolor.d nets
oGeothermal(Heatkat Remarks)Return) OOther(explain under#21 Remar s) sn;t rock era;n tee i
4.Date Wells)Completed: I Well ID# ft. ft. 'JL S
ft. ft.
Facility/Owner Name t } Facility M.'(ifapplicable)
Physical Address,City.and Zip
County Pa_'ccl Identification No.(PIN) s e
_„ rf i rnJ�,�y31Iti.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees; r I'eacte 41
pj
(it'wcli ticid,one ia`long is sufficient) /2.Certification:
6.ls(are)the well(S): C1Permattent or DTemporarp Sign ure ofCertitier:well Contractor Dare
Bt•signing rh&form.I hereAr r ertili that the wrll(sl eats(i+err)rvnslrucred in rr(,•ordance uirh
7.is this a repair to an existing well: DYes or (No 15A.VC 4C 0?C At00 or 15.4 XCAC 02C.0100 It'elt Cosrcrrvtxiva:Standards and that a Copt
!j'rhis s a repair.fill out known well ronsrnmion injonnotinn and plain the nave nfrhe of this record has brrn prorided m rhr vrll owner.
repair raider#21 remarks section or on the back ofthis farnr' •Site diagram or additional weII details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional w=ell construction info
construction.onlv_J,,l3W-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Be-,).You may also attach additional Pages if necessary.
drilled: jE � 24.SUBi9 MAL INSTRUCTIONS
9.Total well depth below land surface: Jft Submit this GW-i within 30 days of well completion per the following:
For nadriple wells list all depths ii(differenm(i temple-3(ar_00 and 2@1007)
24a. For All Wells: Ori;iaat form to Division of Water Resources (DWR).
10.Static water feel below top of casing:�� (ft) Information Processing Unit1617 MSC.Raleigh.NC 27699-1617
1 j voter leer!is Whore ca;;irig.'�i'e`'+"
11.Borehole diameter:6 1/8 (in.) 24b•For Injection Wells:Copy to DWR,Underground Injection Control(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 enz•ironmental healtb`deparlment of the county where uLswied
FOR WATER SUPPLY WELLS ONLY:
4d For Water Wells producing over t4(i,000 GPD:Copy to DWI2,CCPCUA
�] Air Lift PermitProgrant,1611 MSC;Raleigh. -C27699-1 61 1
13a.Yield(gpm) U` Method of test:tab•Disinfection type:ChIOr. Tabs Amount: 1 1/2 Lb
s 4
j
Foray GW-I North Carolina Department of En6ronmcntal Quality-Division of Waror Rccourccs R_vise:d 6-6-201A