GW1-2021-02596_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(Gal-1) For Internal Use Only:
1.Well Contractor Information: a !�
Alfred Kiesling Sri
FROM TO DESCRIPTION,
We))Contractor Name ,� A allft. Ct.
2670-A Ai' `3
`j `l
NC Well Contractor Certification*lumber
t�^r i•.e�.,- Y 'ERC11G#"rmi. sed: s (fHi:tivE12
.t'! •able ?:
ion
B & K Well Drilling Inc �;if�s .���lti't�„�^t FROM TO DLUIETERfin-
THICKNESS MATERIAL
p fr. —ft. 61/4 SDR-21 PVC
Company Name .
kC4: ER�t:OR3T`I3B�6 ee�esiaa}et'oseii >
2.Well Construction Permit# FROM To DIAMETER SS THICKNE MATERIAL
List all applicable well construction perinits,,r.e.UJC'.Cormty.State.Variance-utc-) ft. ft. in.
ft. fit. in.
3.Well Use(check well use):
>'1:Y
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNFS MATERIAL
❑Agricultural ❑MM iciPat/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ^l3Residcntial Water Supply(single) g. fL in.
❑h dt str taCon u ru al ORes rde ttal Water Su
pply 1Y(s
hared)
)
-
O lrri ation ❑Wells>100,000 GPD FROM To I IYU TERIAL EMPLACLMENT METHOD&A 1OUNT
Nun-Water Supply Well: 0 ft. 20 fit Bentonite Pour
OMonitoring ❑Rccovcry- fr- ft.
Injection Well: ft. ft.
❑Aquhfe ec arse ❑Groundwater Remediation
r R h _
❑Aquifer Storage and Recovery ❑Salirtiry Barrier FROM TO MATERIAL, EMPLACF.11-IEIVT METHOD
CAquifer Test ❑Stormw'ater Drainage fit. fr.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 28:331t7LC3iYGLOG 9ttxcfrafter AT:3Y6etis3l tteces3arvl':;:::?>?'%'':%:':
FROM TO DE.SCRIPTION color. ness.soWl k .o atce.etel
❑Geothermal(HeatinJCooline Realm) ❑Other(explain under#21 Remark) p1 tt. , ft. e .
4.Date Well(s)Completed: `L -a[ Well ID# 5'S fit. S fie. U
ft. Ct.
Facility/Owner Name Facility M#(if applicable) ft. fL
ft.
Physical Address,City.and Zip
L_.\Im CI `iI�
County Parcel Identification No.(Pal)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(ifvcll Field,one latlong is sufficient) 22.Certification:
N W.
6.Is(are)theweU(s): OPermanent or ❑Temporat•c
Siguat a ofCenified Well Contractor f Date
��[[_ Brsigning this•foim.l herehv rertf that the,:ell(s)was(r�rre)constrvrred in orcordance nirh
❑Yes or 0 12U NCAC 02C.0100 or 1S.a NC.iC 02C'.0200 Mell Construction Standards cad drat a Coln'
7.Is this a repair to an existing well
!(This is a repair.fill our known well construction informminn and lain the nature nj the of this rece rd has been prorided to the xe//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 thr back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of-,ells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ®5' (R') Submit this GW-1 within 30 days of well completion per the following:
Fa•rrudriple cells fur all depilus if dii ferent(Trample-3(a)200-and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (fit) Information Processing Unit,'1617 MSC.Raleigh,NC 27699-1617
ff order level is abar-e casing.use"+'
6 1/8 24b.For Infection Wells:Copy to DWR.Underground Injection Control(IUC)
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.) county en%ironmental health department of the county where imtalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodncing over 100,000 GPD:Copy to DVVR,CCPCUA
Air Lift PrnnhtProgam,1611MSC,Raleigh.NC2 7699-1 6 11
13a.Yield(gpm) Method of test:
13b.Disinfection type:
Chlor. Tabs Amount 1 1/2 Lb$
Fonn G W-1 North Carolina Department of Env ironmcmal Quality-Division of Water Re§ourccs Revised"-2019
i
I