GW1-2021-01613_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: op
,.,,._,
Alfred Kiesling Sr _ :.14.�1:xT�z ........... ::::.:.::::::
Well Contractor Name 4 FRODI TO DMIlltPTtON,Soft
ken
NC Well ContractorCerification?lumber l
F'i ii1'S,Y�Fi'I'FiltNts;' w��§ed'�c]ls'i;3&'•i�B;4Y ><;>:;;::;:::,:
B & K Well Drilling Inc �:t���,ri�� R ��t:o1, FROM TO DIAMETER THICKNESS MATERIAL
0 ft /_IS ft. 6 1/4 1° SDR-21 JPVC
Company Name
•� ::>k&:�3.1TiVaER:?� f:11itE'�TBL� ker•3�3' ..
2.Well Construction Permit#•�?/ FROM TO DlA.virrER Te1CKNFSS MATERIAL
List all applicable wall construction penn`iari.e.UIC'.COutItV.State,parlance.a .) R. ft. in.
3.W ft.ell Use(check well use): i
:<•::;
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WaterSu Well: :,.::::<:;:.:::.:;
Supply FROM ........TU.:....... DIAMETER $LOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public tt. fL in.
❑Geothermal(Hcatins/Cooling Supply) V-11dential Water Supply(single)
Residential Water Supply(shared)
e O •;::<>::>••r.>x;;;;o-;:;<:,.>;;::,.,...;::;::<s;>: ::"u>;<i2:::;i>• <;it';Gi:;::>:::<:<;;•:;xc;:;:':
Olndustnal.Conun rctal PPY( i13i RC1>Jf>:.......:::::;;......<
❑Irrigation ❑Wells> 100,000GPD FROM TO bi<TERIAL I EDIPLACE4EI%7niETHUD&.-iNIOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour
0\4onitoring ❑Rccovcry It. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,•:.:.::;..,.;::;:>.:::>>;:?'tin?<:iz:G;;:;; ?:?:>:>:<> :'>"i:`•?: <zz ?i>:>:
;:113:5:�-BTGiLiv�:;�?Y�.(� le)•;;i:;<::.:::.:..:.::::.....,,,.:::...:............::.........:....
❑Aquifer Storagge and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI_4CEMFM MMOO
CAquifer Test ❑Stormwater Drainaee fL ft.
OExperimental Technology ❑Subsidence Control fL ir-
❑Geothermal(Closed Loop) ❑Tracer sri: ilTGi `stiadrattueEsttsiFiiecessatxz>isSi::>::>;::>;<"::'<?>;::>?;:>>`.::::*>
❑Geothermal(Heatin3/Coolin2 Return) ❑Other(e:tplain under#21 Remarks) FROM To DESCRIPTION f-M,hardn SOWroek SiZG erGI
rt. I Z, fl- r A �
4.Date Wells)Complete '�- ' Well ID# �� t. fL
ft. fL
Sa.Well Location:
Facility/Owner Name Facility M (ifalp�pliwble))
Physical Address.City,and Zip
+7
(( �Y
0 v�
�nr.Calw
County Parcel ldentifica ion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
N W 3 - 5- a
�ofCerTjfied Well Con or Date
6.Is(arej the well(s): PJPermanent or OTemporars
Bi•signing;this Jorm.l hereln-rertifi;that the+:ef!(q+ws(wrrr)ronstrucied in arc-&dance+.•irh
7.Is this a repair to an existing well: OYes or 0 15.4.NC4C O:C.OIrN)or IS.4 NGIC 02C.0100 MenCo+anuction Standards and rlmt a coin
lfth`is a rrpair.fill out kno-n well c•onsincrtiwr informotint+and a lain the nature o(rhe a(rhic record has born prm•ided to the urll owner.
repair n,rder*21 rema,ks section or on the back oft/ris form. 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
consmuction_only 1 GW-1 is needed. Indicate TOTAL NUMBER of-,ells (add'See Q:•ee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5a (ft) Submit this GW-1 withi°30 days of well completion per the following:
For nruhiple it-ells list tdl deplits if tlifferent(example-31(N=00 and 2(d100�
24a. For A8 Wells: Original. form to Division of Water Resources (DWR),
10.Static water level below top of casing:`A ho (ft•) Information Processing Unit,1617 MSC.Raleigh,NC 27699-1617
lf++xder.levrl is abut•e ebsing.use"+•'
l 1.Borehole diameter 6 1/8 (;n.) 24b.For Injection Wells:Copy to DWI?.Underground Underground Injection Control(IU
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Rotary 24c.For Water Supply and I n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc,) county environmental health department of the cotmty when installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-161 l
13b.Disinfection type:ChIOr. TabsAmount: /2 LbS
Form GW-1 North Carolina Department of En,ironmcntal Quality-Division of Warer Resources Roviscd 6-6-201%