GW1-2021-06517_Well Construction - GW1_20210809

CORD (
For Internal Use Only:
WELL CONSTRUCTION RE (_'�)�'� ,
1.Well Contractor Information:
Alfred Kiesling Sr Ia�iall IztEs
o-�• (� NI TO DESCRIPTION
LF J�O ��rt. ` ft. .J G
Well Contractor Name '�J
2670-A �;�� / p ft. ✓
Cf' �O`� : 11. O' ........ 'Lsells'Ei1Z Et�7$it' {
NC Well Connector Certification Number v t0 (•'\` TO DIAvET.ER .THICKNESS MATERL�i.
Q� ^ Ja,� FROM
B & K Well Drilling Inc OlsR��. 1 '" SDR 21 PVC
p ft rt. 6 1/4
-^T` �.�' ert�extial°glossa loiS
Company Name �t j� DIAMETER 7 HICKNkSS MATERIAL
!/ FROM 10
2.Well Construction Permit#:
7 b ft. ft.
List all applicable well cot structiott permits 6.e.VIC,Cotuttc.State.Varian".etc.) ft. ft. in.
3.Well Use(check well use): 17:SCf1EE1v': .
FROM TODIAMETER CLOT SIZE THICKNESS
......,MATERIAL
Water er Supply Well: O��MunicipaUPublic
gft
ft 7°
❑Agricultural IY(sm ft in
n�Cooling Supply) PJasidenh al Watel Supply(single)
OGcothermal Weati '.❑lndustria]1Conuvercial OResidential Water Supply(shared) l t;R .; ED LACEMENT METHOD&AMOUNT
FROM TO .MATERIAL
Olrri�ation ❑Niells>I001000GPD 0 ft. 20 ft. Bentonite PDUr
Nun-Water Supply Well: ft. ft_
OMonitoring ORu o�'cry'
ft. ft.
Injection Well:
OCirouudwater Ramediation
❑Aquifer Recharge 34 SANtGfCdV1 P4CK 6f 'hcabte EMPI ACEntENT METHUD
❑Aquifer Storage and Recovery OSaliniry Barrier
FROMTU MATERIAL
ft.
❑Aquifer Test ❑Stormwater Drainage
Ct.
ft. ft.
❑Experimental Technology OSubsidence Control --
ZgBifif GliVCr1. attacheddi IteCl33S.nec saa
iuA
❑Geothermal(Closed.Loop) FRopt TU DESCRIPTION(color.hardness so rock in size etc.l
❑Tncer
❑Geothermal(IleatinoiCooling Return) ❑Other(explain under#21 Remarks) ft. ft. ` f
4.Date Well(s)Completed:_?�f a'/Well ID#
ft. `p 7 ft.
5a.l Well Location: ft• v
Facility/OL-viner Name Facility lT)."*(if applicable)
ft. ft.
ft. n•
Physical Address.City.and Zip �<i;":7tI�1ARfi5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: w
22.Certification:(if well field,one lab/long is Sufficient) `^ -
S azure Certified Well Co stop
ate
6.Is(are)the well(s): nPermanent or ❑Temporary
Brsigning this%arm.!hereht:rerti/v that the.:rll(s1 s(werPl consnurted in accordance with
I sA.NCAC 02C.0700 or d4 N-6C 02C.020n If'-ell Cattttrtrction Standards and rlwt a color
7.Is this a repair to an existing well: ❑Yes or ONo a(dtis record has been proridrd;m the xrll owner.
g'rhis is a repair.fill out known well construction in(artnatinn and explain the nature n f the
repair under#21 remarks section or on the back of'this fornt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See O'er'in Remarks Box).You may also attach additional Pages if necessary•.
construction in 1 GW-1 is needed. Gidieatc TOTAL NUMBER of wells 24 SUBMITTAL INSTRUCTIONS
drilled:
rface: (R') Submit this GW-1 within 30 days of well completion per the following:
9.Total well depth below land so
Fur multiple yells list all depths if thfferent(e_rrunpfe-3(aC00'and 2(a!100�
24a. For All Wells: Original form to Division of Water Resources (DW'R),
( ) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
10.Static water level below top of casing:
ft.
fjirater level is above casing.the"+" 24b.For Infection Wells:Copy to DWR Underbrround Inieetion Control(IUC)
11.Borehole diameter:
6 1/8 ( •) Program,1636 MSC,Raleigh,NC 27699-1636
Air Rotary 24c.For Water Supply a Id Open-Loop Geothermal Return Wells.Copy to the
12.Well construction method: county environmental health department of the county"•here installed
(i.e.auger,rotary.cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 24d.For V1'ater Wells producin);over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) / Method of test.
Air Lift
PcnnitProgram,1611MSC,Ralctgh.NC276991b(t►t
Chlor. Tabs Amount 1 1/2 Lbs
13b.Disinfection type:
f Revised 6-6-2019
North Carolina Department of Environmental Quality-Division of Wald Resources
Form GW-I ,
f
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