GW1-2021-06119_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1} Far internal use Only:
1.Well Contractor Information:
Alfred Kiesling Sr >a4.A A°1'E> o `
FROM TO DE'•CRIPTTOti
Well Contractor Name ,; } t.
2670-A "L rt.
NC Well Contractor Certification Number
i<;13ai)if7?EitiCiASi11i6":fsrtecssed ivelLs':E?Ii: fvft'Lf a>ite'> :`:'%''i'::>:;'.<.::
Br& K Well Drilling Inc FROM TO D1kMETER THICKNESS MATERLIL
0 ft. 3 r+ l- 6 1/4 j i° SDR-21 PVC
Company Name
,3:6 Ii+AVER:C� G OR:: I:�74"s: cet3terslat cltaedX.
2.Well Construction Permit#: FROM '1'0 i DIAMETER THICKNESS I MATERIAL
List all applicable well construrdait perinia;ex.Lr1C.Coraety.State.t%ariatrox-.du.j CL_ ft. in.
3.Well Use(check well use): R. It. in.
Water Supply Well: 1:7;.$t3tl ElV
ppy FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Publie ft, ft,
OGeothermal(HcatinglCooling Supply)
tesidential Water Supply(single) f. fL❑1ndLsirisl! onuuercial esidential Water Supply(shared)
Olrriaation OWells> 100,000GPD FROM TO M.%TERIAL EDIPLACEMENT METHOD&A0 fOUNT
Non-Water Supply Well: O rt_ 20 ft_ Bentonjte Pouf
OMonitoring ORccovcry ti. ft-
Injection Well:
OAquifer Recharge ❑(•groundwater Remediation
9:S9P S GRa_rL PA+3C fif ble .. „ :;:sr.,
❑Aquifer Storage and Recovery ❑Sahniry Barrier FROM TO MATERIAL EMPLACEMrM METHOD
OAquifer Test OStormwater Drainage Ft. ft-
❑Experimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer Z t#ItTI LitVG:€f►G Ssiaclsadd3tt+;p' site fa.It Fes a
FROM TO DESCRIPTION tcol6r,ha nesu soiVrark type._rain She.etc
OGeothemtal(.HeatinglCDoling Return} flQther(espiain under#21 Remark s) ft. ft.
4.Date Well(s)Completed:? 31 94vell iD# `' rt ft.
ft.
Sa.Well Location. �R-
Facili :Owner Name FacilityM.'', (applicable) ft. ft.
ft. ft.
Physical Address,City.and Zip
'.
�i:`ttI�Rtt3::„
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilone is sufficient) 22.Certificatio
N �• IJ t`J -7
6.Is(are)the well(s): Permanent or ❑Temporari ofcertifieQ well contract Date
Br signing ttris fnr7r.1 herel,.r vertf(i shot the i:rit(s/ices(tyere!r?nstrur•iet.in ae:nrdanre Frith
7.Is this a repair to an existing well: OYes or / No 15.-1:VCAC 02C.o1p4 or IS.a&,*CAC-0_'C.1)1p0 neli Cortitruction Standards L;nd ilwi n eolry
tl rhia LL a repair.fill out kootrn wr//rnnstna:rirni informarinn and eiplain the nature nJ rh<> nfrhis record bus brrn prnrfdrd to the r11 ownrr,
repair n,rder#21 remar leer 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-I is needed. indicate TOTAL NUMBER�of wells (add'See Oaet'in Remarks Btix).You may also attach additional pages if necessary.
drilled: -- 24.SUBMITTAL INSTFtCJCTTONS .
9,.Total%veil depth below land surface: 1 (ft.) Submit this GW-t within 3U days of well completion per the following:
For mldriple trell8 list all deprlis if efiffoent(i:uunpte-3(at200'unt!?(d!ItT)�
24a. For All Wells: Original formto Division of Water Resources (DWR),
10.Static water level below top of casi ng:�0 (ft-) Information Processing Unit;1617 N1SC.Raleigh.NC 27699-1617
IJ'awo tevel is above cositig•use
!1.Borehole diameter Ij 1/8 (in.} 24b.For Injection Wells:Copy to DWR,Underground lnjection Control(IOC)
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 environmental bealth department of the county where instalied
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DNrt'R,CCPCUA
13a.Yield(gpn) � Method of test:Air Lift
Pctrmit Program,1611 MSC:Raleigh-NC 276W)611
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 LbS
I
Form GW-I North Carolina Department of En%iroamental Quality-Division of Water Resources P.cvised 6ib-2018
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