GW1-2021-01611_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GA-1) For lntemal Use Only:
1.Well Contractor Information: E
• ,M .. ;:...•:.....:...:..........:: ^:;.: is:.•':
Alfred Kieslmg Sr i WWW 74..`7;a r zol!Tls ::::::...:.
FROM I TO I DE.SCRIPTiO\
Well Contractor Name 20t)116V. tt.
(L-
2670-A A►' 1 to ft. ft.
NC Well Contractor Certification Number 0�'t](^L
E>�JI�d�LJfSI! :.:.... ....:.:...
_ >YSi�.t'FERGib,$N�`:`fermtttLl-ka§ei��elk"E1R:it41�Y '' s�ie';::: :.>:":'�:::;;;:;:
B & K Well Drilling Inc �''� lIi3c'. ��^f,011 FROM TO DL1nETER THtChNESS MATERLAL
��� p fr ` ft. 61/4 in SDR-21 PVC;
-
Company-Name
FROM TO DIAMETER THICKNESS MAl'ENI.AL
2.Well Construction Permit#: ft. ft. in-
Cist all applicable well construction permits i.e.UIC.Coronrv.State.VaHoace.eie.j
ft. ft. - in.
3.Well Use(check well use):
.:. ...... .....Nils:>:'
SGTt7,,,E.............. ....Water Supply Well: FROMTO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ft in•11c f -
❑Gcothennal(Hcating/Cooliug Supply) $Residential Water Supply(single) ft. (L in.
d
t •al ORestdrnhal Water Supply(share )
❑lndUSCCIaI.C On1n1CCc 1 'y"'.:5>:^�
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL I EDWLACEMENT METHOD&:11tOUNT
Non-Water Supply Well: 0 fL 20 fl- Bentonite Pour
❑Monitoring ❑par-occry
Injection Well:
❑<irouudwater Remadiation :;:;:<z^::;.:>:z>;:..............< :><
❑Aquifer Recharge ?Gt134t:PfY :fth ieY ; :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainaee ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer Z9:113E11 Gi;AIE:LOG.�ff�ctra�tEienei:s7beds3#neccssatx3::':?>:<::'
FROM TO DE.SCRIPTfO1.; color. ,ass.sods—k is size.« 1
❑Geothermal(HeatinJCoolin_g Return) ❑Other(explain under#21 Remarks) p,, ft. • ft. '
4.Date Well(s)Completed: -L Well ID# V'Sft• S ft U
S`a.Well align: ® �J
Facil ity/Oaner Name Facility n) (if applicable) ft. ft.
7 �e- ft. ft
{-\ham �� .
ft. fr.
Physical Address,City.and Zip -" ..
RP3S�LARYa County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwcll field,one latlong is sufficient) 22.Certification: / ']
N w
Signal a of Certified Well Contractor Date
6.ls(are)thewell(s): OPermanent or ❑Temporary
Al-signing this Irian.I herehv eer 4h:that the I:011(s)was(werr)eonstr-uc•ted in N.C.6rdmu'e with
7.Is this a repair to an existing well: ❑Yes or o t s.t:vCaC 02C.010n or 15.a 1vGaC 02C A10n If'eR Cautruction standards and drat a cajre
ff this is a repair.ill out known well eansrna-tirm infannation and lain the nature of the o(this record has been prorided to the well owner.
repair wider#21 remarks section or on the back of ilds form. 23.Site diagram or additional well details:
You map use the back of this page to provide additional well construction info
c For Geoprobe/DPT or Closed-Loop Geothermal NU having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction_only 1 GW-1 is needed. Indicate TOTAL NUMBER of.yells ,.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 ® (R') Submit this GW-1 within 30 days of well completion per the following:
Fur•multiple,'ells list all depils if different(example-3(a)200'and 2Cd100) i
lda. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft•) Information Processing Unit,11617 MSC.Raleigh-NC 27699-1617
!(writer level is abor'e casing.use"+"
6 1/8 24b.For Injection Wells:Copy to DWR Underground Injection Control(IOC)
11.Borehole diameter: (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,rotary.cable,direct push,etc.) cour y environmental health department of the county where intitallcd
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells.rodbeing over 100,000 GPD:Copy to Dv:R,CCPCUA
Air Lift permprogram,1611 MSC,Raleigh-NC 27699-1611
13a.Yield(gpm) L Method of test: it
Tabs
13b.Disinfection type:Chlor. Amount: 1 1/2 Lbs
j
Revised fi b-201 AFonn G W-1 Nonh Carolina Department of En,ironmental Quality-Division of Water Resources
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