GW1-2021-06116_Well Construction - GW1_20210809

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For Internal Use Only:
WELL CONSTRUCTION (GW-11 Well Contractor Information:
Alfred Kiesling Sr FROM DESCRI 'ION
Well Contractor Name ft. J'a t. t
ft. 0 't. t)A
2670-A
--rEN:NC Well Coutr8CWT Certification Number r,4ATER]l
FROM T1111 11 DLV DR-21 PVC
B & K Well Drilling Inc 0 ft. Jill 61/4 in. Sf
D=ol
- - raim closed,
A&A-NERirAS1NG:0RTUBV4k-
Company Name
i.Well Construction Permit FROM ft. To DIA.Mill in. I'HICKNESS MAIERIAL
List all applicable well construction permits 6,.,.LTIC'.Cowim State.11alialfc,'.ell)
3.Well Use(check well use):
FROM TO DIAMETER SLOTSIZE THICKNESS Nl..kTCRIAL
Water Supply Well:
in.
C.;kgricultur3l unicipal/Public ft.
D oth rm*31(Heatins�iCOOlilIg Supply) Water Supply in.
Ge e nResidential
01ndustrial!Conunercial DResidential Water Supply(shared) ::f9..GR0Il
Olrri I gation OWells> 100,OOOGPD rRO!%1 To
Nun-Water Supply Well: 0 ft. 20 t5ell IlLf-- li
OM01iitoriilg ORccovcry ft.
Injection Well: ft. ft.
DAquifer Recharge 06roundwater Reniediation
0 Aquifer Storage and Recovery Barrier FROM TO
TO MATERIAL
tt
CAquifer Test oStorMwaTeT Drainage
ft tt.
ciExpeTimental Technology OSubsidence Control ...
GGeothermal(Closed Loop) ElTracer 6 ai jt- ill
FROM TO DESCRIPTION mill 11/ k
oGeothermal(Heatikiz/Cooling Return) 00ther(explain under#21 Remark-,)
t.
4.Dalte Well(s)Completed: Well rD#
5a.Well Location:
Facility/Owner Name Facilitv 117) (ifapp!icable)
Ale- ft.
Physical Address,City.and Zip
sv
County Pluccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if,,cll field,one lat/long is qutYicicni) 22.Cerlit -7
N
1.g(are)thewil [nPermanent or OTemporary Signature dill It Contra tor Date
6.
'61-si.gni this.16p.m.1herehr tet-n/J:that (1v e)(*onsim<.fedinai4-ordmi(,tvirl?
7.Is this a repair to an existing well: GYes or (!lNo 11.4..VCAC 02C.0101)or 15-4 KC.4C 02C.0200 If'-ell Colutruction Standards and t1i cone
co
ofthis record he.,bee,,jn,-o,-idrd to the xrll owner.
11 rb�is is a repair.'if our knoi-well oonunr<nin»in.jorn`lajjn,j and exploin the nature qffl?e
repair under 421 remarks section or on the back 00hrifio— 23.Site diagram or additional well details: traction info
use
(add'Seevee in Remarks Box).You may also attach additional pages if necessary.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same you may e the back of this:page to provide additional well coils ssary
construction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells
O I
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'Ve 6 _(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all elei if(liffel-eal(e.wini 3(a1200 and 2�'4U00'.)
24a. For All Wells: Original form to Division of Water Resources (DA'R),
10.Static water level below top of casing:40 ft Information Processing Unit,
1617"MSC.Raleigh.NC 27699-1617
ff,­ter le,el isab.,-e Casing.use 24b.For Injection Wells:Copy to DWR_U rg nderound Injection Control(IUC)
11.Borehole diameter:61/8 (in-) Program,1636 MSC,Raleigh,NC 27699-1636
14c.For ' Supply and Open-Loop I GeothermalWells:Copy to the
Up _ Return-twit:u
12.4ell construction method:
Air Rotary r Water
fi.tl Totary,cable.direct push,etc-t countyenvironmental health department of the county
where ulN
I FOR WATER SLTPLY WELLS ONLY: 24d.For Water Welts producing over 100.000
G Copy to DWR,CCPCUIA
qq
Air Lift Pennit Program.1611 MSC,Raleigh.NC 27_699-
13a.Yield(gpm) Method of test
I
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
North Carolina Department of En,irolunental Quality-mvisiorl\,Vatcr Reslourccil; Revised 6-6-2019
Form G W-I
I