GW1-2021-02286_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD fGW_.�J For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
5.—'� FROM TO DECC.RIPTt0N
Well Crnrtractor Name 2670-A "7 ft. 1A5,
tt.
C SAY 2 loll / n '7
NC Well Contractor Certification Number 1 1I1( :�'.l:S Rb:LY'f,Flt:JE :Si` ski(Cj'faicID tca+3ed elli':UR$.tNl t2 1�^.:
B & K Well Drilling InCi►IiGIIi I�� .c�cC�t,1JI1 FROM TO DLdL4ETER THICKNESS MATERLAL
ta () tt. f- 61/4 in ISDR-21 PVC
Company Name tS 3I £It'CA"+I1�1G:"ORB mo:
��tt ��//�� 7 '• I
2.Well Construction Permitd#:,"�.ZI � 54c.2/✓ FROM To I PIA." rER I THICKNESS MAT; IAL
List nil applicable well coturruction permits i.e.U1C.Cotat".Stale.yurthlrcc.etc.) ft. ft• in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: ;'t!7 STLEEa1E;:' f.
PpyFROM TO I 01AMETER I SLOTSIZE I THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft• fL in.
OGcothen-nal(HeatingiCooling Supply) 2<esidential Water Supply(single) ft. tt- in-
OindustriaKontmercial OResidential Water Supply(shared)
'ait:fiit(l>3
Oirrigation 0Wells> 100,000 GPD FROM To NVITERLAL EMPLACEMENT METHOD&.010UN'T
Non-Water Supply Well: O ft' 20 ft. Sentonite Pout
O\401litoring ORccovcry ft. ft.
Injection Well:
ft. fr.
OAquifer Recharge O(iroundwater Remediation
4z�sfa.4iV9?GftAY�1,.-a34Ci�.Fxt'":.3xeablet:.•:% "" "".:::....... :.." .....:.. .....:.'
❑Aquifer Storage and Recovery OSalinicy Barrier FROM To NIATERIAt. EMPl_ACEhi Fd9T METHOD
CAquifer Test OStormwater Drainaee ft. ft.
OExperlmental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 21#7R1)Y[#lL ?attach'ad�,li»isal:siieeta#€ `avf:> ': ;:s
C)Geothermal(HeatinJCooling Retum) OOther(explain under#21 Remarks) FRont To DESCRIPTION(wi r,hxrdtitss sq Urock n s ze etc.i"
V ft. 0 ft.
4-Date Well(s)Completed: Well fD# ft. ft.
5a.Well Location: ft. -rig f X(�b
Fa__ci77lity/Owner Name
+ Facility M#(ifapplicable)
Physical Address,City,and Zip ft. ft.
23 RlltixR. 5 ..: r
County Pa cd Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if u,cli field,one iat/long is surticieni) 22.Certification:
6.ls(are)the well(s): dPermanent or OTemporar} igrtat e ofCenified Well Contractor Date
At-signing Chic form.!hrrehr rar'rij that the+:.rll(sI nos(nrm)<onsaut re,?in arcardartre+rich
7.Is this a repair to an existing well- Oyes or !No i s,4 NCaC 02e.0101)or l5',4.tv'C,lC 02C.020n JI'ell Couttruchon Standards and t1wi a coin,
11 rhis Lr a repair.ill out known well conrr za:riore iafnnnarinn cord etytloi.n the nature of the gfthis record has bren provided;to rho xrll owner.
repair under*21 remarks section or on the back of this.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
construction.only I GW-1 is needed. indicate TOTAL NUMBER of ucils (add'See Ovee in Remarks Box).You may also attach additional',.tages if necessary.
drilled, 24.SUBMITTAL INSTRUCTIONS
4.Total well depth below land surface: r4 el s (ft.) Submit this GW-1 within 30 days of well completion per the following:
For muiriple+tells lit ill depihs(felierent(erntnple.-3(4l_00 and-(a!100)
,t 0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:`t (ft-) Information Processing Unit,1617 MSC.Raleigh-NC 27699-1617
1 f order le+.e1%r abo+'e casing•use•'+" _
6 }f$ 24b.For Injection Wells.'Copy to DWR.Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleig.;h,NC 27699-1636
12.Well construction method:Air Rotary
2.1c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county entironmental health department of the county where im:talted
FOR WATER SUPPLY WELLS ONLY: 24d.For W W
nit Program,1611 MS
ater ells producing over 100,000 GPD:Copy to DWR,CCPCUA
Air Lift PenG,Raleigh.NC 27699-16 1 1
13a.Yield(,•pm) �0 Method of test:13b_Disinfection type: Chloe. Tabs Amount- 1 1/2 Lbs
i
Forth G W-I North Carolina Department of En.iroomenta)Quality-Division of water Resources : Revised 6-6.2019
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