GW1-2021-06117_Well Construction - GW1_20210809

trorInterna7lUSe
RECORD(GW-�
1.Well Contractor Information:
Alfred Kiesling Sr ""`ATER
FROM TO DgcCRiP,TION
cVtllCrn,tractor Namt / -
2670-A � L � it. �
15sUFr1ER: t(t israa C89Cd ()RFINER1lf' ahl@
NC Nell Contractor Certification Number FROM TO DL4SIETER THICKNESS MATERU-L
B & K Well Drilling Inc io it. ft. g 1l4 in- SDR-21 PVC
Company Name 1AL-I 1NERbC4MNG ORAIjAsLtG '�?rtnalstosed loi 3 MA ERI(L
s9 /� FROM UTA�1E'ItR 1HICK♦tS5
fl it. n.
2.well Construction Permit�: I-ar;r,rt�e.etc.1
Lrsr a,i applicable well cunsnuction permits%'.c UK-..Coots. irate. ft ft. in.
3.Well Use(check well use): t:7SGREE '
FROrI TO DIAMETER CLOT SIZE THI(KAE$5 tit aTER1AL
Water Supply Well: ft. ft. in. {
OAgricultural OMunicipaUPublic
tsidential Water Supply(single) ft. s"
❑Gcothennal(Heat inJCoOling Supply) -
❑Residential Water S pply(shared)
❑lndustriaUContrnercial FROM To M.\TERI.0 EAIPLACE?IEs7METHUD&AStOUNT
0lrrioation ❑wells> 100,000GPD ft. 20 ft. lBentonite 1110ur
Nun-Water Supply'Well: ft ft-
❑NIonitoring OR,:ovcy
ft. fc '
Injection Well:
O6rouudwaterReniedianon aY
FRoal TO
9,5 �iGRaoEL:P_4GKL+f le
CAquifer Recharge NiATFRIAI. EM P1,.4CFMENT MF.THOO
pA Osalilliry Barrier quifer Storage and Recovery fc. l ft.
OAquifer Test OStormwater Drainage
0Experimental Technology GSubsidence Consul
ft. R
OTre ter dZ9 Dit1111(VG i.:OG,attack a�'.iiikyel sLeefs$f necessiiiv
OGeothermal(Closed Loop) FROM TO DESC.RIPT70�(cobs h rdness w,Ureck cram»ze.er.1
fit j
OGeotherma](Heatins/Coolino Return) OOther(explain under,421 Remarlrs) 0 ft.
4.Date Well(s)Completed:��—fi'_"T—Well ID#
i
ca.Well Location: I fl, ft•
0-e h rC �f1)♦ c t _
(� FadlityTT) (ifxpp!icab!ti
Facilit`y/OarrnerName
3t (;W
PhySi xl._,,dress,City.a, Zip - '>: '
-;2t:RE3Yi'ARIiS
lY� Parcel ldc-i ificam)n No.(PIN) yet
(.Aunty
5b.Latitude and longitude in deg or decimal degrees: Certifica n- till-,rr�Dw C3,eC31On
iit ecii ticl(i,one Iavlona k sufticicnt) . �/
rij
N w AV 'L i
Siezat ofCznitizd`Nell C. nvacuor
Date
6.Is(are)thewell(s): OPermanent or OTemporan' rrr nsavrredin arrorda„re:ath
Br s:Vining this lnrm.!hrrehr rrrriJii sans ri,e i:r sJ,rns(,�' )"'
15.4 NCAC O'C.OIOn or IS 4 NCaC 0 C.n200 11'"11 Cortsrruction Standards and that a cOID:
7.Is this a repair to an existing well: GYes or nNo of this retard has been pm,-idrd in rhr v.rl/ow rr.
L/rhis is a repair'.fl/out kao,.n well rnn.gnaira,1 infortnorian and erpiaia thr nmurr?t thr Site diagram or additional well details
repair under ti31 remarks section or on the hack of ilmsrn fo* .
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (acid'See Ovee iu Remarks Box).You may also attach additional pages if necessary.
construction.only 1 GW-1 is needed. indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled: I —: n
9.Total well depth below land surface ��y (ft.) Submit Ibis GW-1 within 30 days of well completion per the following:
.par multipie❑•ells list all deprhs if drffe,renr(trample-3,41=700 und';i!l0fY) Zia. For AU Wells: Orirnal form to Division of water Resources (DN R),
10.Static water level below top of casing:
40 (ft.) Information Processing Unit,1617 MSC,Ralei---b-ATC 27699-1617
lf,arter le+el rs ab,a casing.u..•a" 24b.For Injection Wells:'Copy to DWR Underground lniection Control(IUC)
6 118 (in.) Program,1636 MSC,Raleiih,NC 27699-1636
L1.Borehole diameter:__— l
Air Rotary 24c.For Water Su ly and O n-Loo Geothermal Return Wells:Cosy to the
13.Well construction method: county environmental health department of the county wbere installed
(i.e.auger.rotary.cable•direct push,etc.) Y
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to D\\'R,CCPCUA
Air Lift PetmitProgl'am•1611 MSC.Raleigh.NL_Z?t,99 !ot I
13a.Yield(gpm) Method of test: i
?I 3b.Disinfection type:
Chlor. Tabs _,mount 1 1/2 Lbs
: I
Revised 6-6-201 R
arolina Department of En,iroamcntal Quality-Division of Water Rewur c
Form GN s
( North C
P