GW1-2021-02288_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-13 For internal use Chily:
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1.Well Contractor Information: ;;
Alfred Kiesling Sr
Well CoirKactorName `r �• FROM TO DESCRIPTION y�
RY9A 7 ft. _(/ 0*.
2676-A +i tJ
rt• rGxS i(1(�U911'{ fL tt I/• �4i�r��d 1��
NC Well Contractor CertificationNumber yw , YiCp) 3atiT3EF1i'" riib'1ot.mveased r�1Es ORI;:tN6tt able
B & K Well DrillingInc UNR` Y FROM I TO 1~ICMETER Tltflt l MATERLAL
0 ft. ft. g 1/4 1n• SDR-21 PVC
Company Name 'td.ji'�'£12 1 ; 'f.�'S�'(;: �ISI{LNG eo�erffiaf clo6edr 3
2.Well Construction Permit# �� <J FROM 10 DIAMETER THICKNESS MATERIAL
Livr all applicable well cousmuction perrniu,ix.UIC.Co...m Sent,.kariance.die.) ft. ft, rn.
in. e
3.Well Use(check well use). ft. ft.
Water Supply Well
PP Y : FROM I TO I otaMErex SLOT SIZE I THtt:KNE$S I MATERIAL -
DAgricuitural DMunicipal/Public ft. I In.
OGcothermal(Heatiug/Cooling Supply) eesidential Water Supply(single) ft. fL in.
e OResidential Water Supply(shared)
r al u ral trio cs Olnd st I Co pP Y
❑Irrigation OWells} 100,000GPD FR0111.. .. To M_tTERLAL EMPLACEMENT?tMOD&AMOUNT
Nun-Water Supply Well: 0 tt 20 fL Bentonite Pour
0h4onitoring ORmovcry ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge D(sroundwater Ramediation
OAquifer Storage and Recovery OSaliniry Barrier FROM To MATERIAL F.M Pi_ACEPIF.NT METHOp
CAquifer Test ❑Stormwater Drainaee it, ft.
❑Experimental Technology OSubsidence Control
❑Geothermal(Closed.Loop) OTracer z T31tTf L3#+l idlir'susch hvit6 s ets: a s' ...
DGeotbermal(Heating(Cooling Return) DOther(explain under-21 Remarks) FROM To DESCRIt TtO� color.n rd soJ rock tt to ma«�i
fc. •D ft. a�:o j
4.Dati Well(s)Completed: to Well ID# '• ft. R. R p 4 j u C-o-f-'e �J
R. ft.
Sa.Well Location:
ft. ft.
F)acility;0icnerName Facility M.4 Wapplicable) ft. ft.
7 173 e� � 1/ fr. ft.
13Y tw.tvt.�d 1
Physical Address,City,and Zip
County Pu'cel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i,ifu•clt field,one laUlono is sufficient) 22.Certification:
N W ( ore 1 �c _s
6.1s(are)the well(s): dPermanent or ❑Temporary' bignat a of Certified Well Contractor Dat¢
Bi signing this lorm.1 herehr c&fi i that the,+eU(s)was(ivere)constructed in accordance ivith
7.Is this a repair to an existing well: DYes or In No 15A NCAC 02C.0100 or)S.J NCAC 02C.0100 bell Corutruction Standards and rivet a co'vy
If this is a repair.ill out known wel!rnnstntrtion infonnatinu and explain the aorure nt the nrihis recnrd has been proi(ded m the m-ell owner.
repair tinder#11 remarks section or on the back ofzlds farm. 23.Site diagram or additional well details
3_For Geoprobe/DPI or Closed-Loop Geothermal Wells having the lama You may use the back of this page to provide additional well construction info
(add'See Ovee in Remarks Box).You may also attach additional pages if nu aty ess
construction.only i GW-I is needed. indicate TOTAL NUMBER of wclls .
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Sy _i (ft.} Submit this GW-I within 30 days of well completion per the following:
For mulrip/e irells l sr all depths if tkfferent(rcample-3(ai100 antl 2(4i100)
24a. For All Wells: Ori.inal form to Division of Water'R,=urc:es (DWR),
S 0.Static water level below top of casing:4t�� (ft') Information processing Unit,1617 MSC.Raleigh.NC 276994617
If*,cwer revel is rrbu+•e casing,use"+'
11.Borehole diameter 0 ��$ (tat.) 24b.For Injection Wells:'Copy to DWR Underground Injection Control(lUC)
Program,1636 MSC,Raleigh:NC 27699-1636
r
12.Well construction method-.Air Rotary 24c.For Water Supply anId Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county ent imnmenral health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
13a.yield(gpin Method of test:
Air l.�ft PermitProDga Im,1611 MSC,Raleigh. C27699-1 6 1I
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
I
Form GW-i North Carolina Department of En+'iroamental Quality-Division of Waror r Resources Revised(rf+-201R