GW1-2021-01924_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) Far lntemal Use Only:
1.Well Contractor Information:
Alfred Ki s ing Srie I'
Well Contractor Name �,�. FROM TO DISCRrmnx
0. tt.
2670-A � 202i �a ft tt. pr
NC well Contractor Certification Number .( formEasel: l§: Ri iNEt
erne+.,iCt�J
B & K Well DrillingInc r Aii^I1tt t t* FROM TO D VIEFER fHtfltNESS MAFERL3:
1'ttCili `Otl 0 SDR 21 PVC
_y�"r;�.- ft. ft. 61/4 to
,17
Company Name �
26s1VER�t":i�R'T'UB�dG."eetlarttmal:cCased- :, '
2.Well Construction Permit FROM To UtAViE'1'kR 1'RItKN MATERIAL
List all applicable well construction permits i.e.WC.Cowry.State.Far.'nncr ere.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
17'
:>`�1:i:
Water Supply NVell:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. tt in.
OGcothennai(HeatinglCoolitig Supply) 14
idential Water Supply(singid) ft. ft in
Olndustriakom niercial OResidential Water Supply(shared)
Olrriaation ❑Wells>100,000 GPD FROM To bL1TERiAL EMPLACEMENT METBVD&.1AIOtJNT
Nun-Water Supply Well: 0 It, 20 ft. Ben)Onite Pour
❑Monitoring ORccovcry ft. it_
Injection Well: —
ft. �ft,
OAquifer Recharge OGroundwater Remediation
—.:.
SA4ti�iCiiid i4Flf:,...._ >:::?, a::<ii;:z':
OAquifer Storage and Recovery OSahility Barrier FROM TO MATERIAL EMPLACEINF.NT METHO
OAquifer Test OStormw'ater Drainage ft. ft.
OExperitnentai Technology ❑Subsidence Control rL
OGeothernnal(Closed Loop) OTracer
ClGeothermal(HeatingfCoolke Return) OOther(ex lain under*21 Remarks) FROM TO ft. DESCRIPTION color.n s., soiVt k . in Az�ec,I
4.Date Well(s)Completed:-3-cl Well ID# ,' L_ft. 2C� t a CA
t. ft
5a.Well Location: (i�f`,r
Facility/owner Name ' e 444
Facility M (ifapplicable) ft. ft.
h 4 J 4 ft. ft.
Physical Address,C'iry�and Zip ft. fr.
,:..t y::`.::=i.:o-s:?>:;a:�x:;•:;<�:�:r`^=:�Rv t-5:::;::�:::::%`:eG:6;::c::c:Ys;::.
L.J h C Ji t^. iJ1 /elj_
County �r Parccl ld unification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwcll field,one lat/long is suffcicnt) 22.Certification:
NW _ ---�--
6.Is(are)the well(s): [!Permanent or OTemporarr' Si tore ofCutibed Well Contractor Date
Brsigning this,fonn.I hereby cerdfv that the %rt/(.r)+vas(!ogre}consrratKed in arc�rdmx a triter
7.Is this a•repair to an enlisting well: OYes or nNo /s.�:vc aC o:C.41gn ar)s.a NGIC n2C o2llrl ilelt Cataruction Standards and vitae a gain
U rhis is a repair.fill our knoun wrll<•nnstnrcaion informarinn and explain the nature of the gfihis raenrd has bren provided to the nrll otvrrer.
repair under 421 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well const action info
construction.only i GW-1 is needed. Indicate TOTAL NUMBER of weals (add'See Over'in Remarks Box).You may also attach additional page:.if necessary.
drilled: "''j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 C— (ft-) Submit this GW-1 within 30 days of well completion per the following:
For mutriple+yells list rt/l deptlu'if<hfferent(eaample-8(eu100 unel 2@100)
10.Static water level below top of casing:40 (ft) 24a, For All Wells: Orizinal form to Division of Water Resources (DWR),
C(uutpr/eve!is ubu a casing,Ise"+" Information Processing Unit,1fr17 MSC:Raleigh,NC 27699-1617
11.Borehole diameter:6 1/8 ( ,) 24b.For injection Wells:Copy to DWR,Underground Injection,Control(WC)
Program,1636 MSC,Raleigh,NC 27699-1636
Air Rotas 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
12.Well construction method: Rotary
(i.e.auger.rotary.cable,direct push,e(c.) county env3t'tmmental health department of the county where in,-talled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to D�\R,CCPCUA
PermitPro�anz,1fi11M5C,Raltigh.NC27699
Alr !_ift -tblt
13a.Yield Win) Method of test: 1,
13b.Disinfection type: Chlor. Tabs Amount: 1 1 I2 LbS
f
Form G W-1 North Carolina Department of Em ironvicntal Quality-Divisicn of Water Rm6urccs F:viscd 6-6-01 K
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