GW1-2021-06521_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(�W1-�
For internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr <.,a..',ar)11;z
� FROFROMTO DESCRIPTION
ft
Well Corrtractor Name v j o ft. L CS T 1,, 1 5/a .
2670-A 42- ��� ��� 7 ft. tt y� �—✓..
t±th ` 15.A)TE11G' form�ii ca9ed�sells E)Ri trt£R r
NC Well Contractor Certification Number Q�l \'G C�
�., TO DLA.METER THICKNESS MATERL4L
B & K Well Drilling Inc °.��� p tt• y� 6 1/4 m SDR 21 PVC
Company Name 243;1`7NER.G4kSINGOlI'I[SBL\TF.. >calhermatcYosEd-lbe
PROItI '1'O UTA�'1 E'1'EIt 'THICKNESS MA
TERIAL
�y ft.
2.Well Construction Permit#: ft. in.
� I 1
List all applicable well construction permits(t.e.U1C.Cola,m State.Variance.e/c.)
3.Well Use(check well use):
Z'SCREE1v. MATERIAL
Wafer Supply Well: FROaI TO DIAMETER SLOT SIZE THICKNESS
❑Agricultural
❑Municipaupublic ft. ft.
m le
❑Geothermal(Heating/CoolingSupply) rdenhal Water Supply(s g ) ft. c;:i;>:>:>s>s3::<<;<:<•;:<;;<>::a;>::;':: i;:;<;»» :
❑Residential Water Supply(shared) "`
❑Industrial!Conrnlercial EE?1ENT ME fRUD&.AAIUUNT
FROM MPLAC
TU MATERIAL
❑Irri ation ❑Wells> IOO,000GPD 0 ff 20 ft.
Bentonite our
Nun-Water Supply Well: EiRccovcry ft. ft.
❑Monitoring
ft.
Injection Well: tt.
❑Aquifer Recharge ❑Groundwater Renrediaiion a :{G y Pq ble
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TU h117.F,RIA1 FIM L ACEMENT METHOD
ft. tt.
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
tt. tt
Tracer :Z0.33R1IUiAlGL atiachaddiiYnBlsltee#s:i£treces[aii
❑Geotherm ❑
al(Closed Loop) FROM 'TO DESCRiPTfO\Icolor.hardness,goil/rock e. m size.etc.l
❑Geothermal(.Heating/Cooling Retum) ❑Other(explain under#21 Remarks) fe ft. �}J I
ft. rt. 0
4.Date Well(s)Completed: 9 / Well ID#
tt. ft. � r
t
5a.Well Location:
C Yb k 71 �9 1(if applieable)
Facility/0—er Maine Facility lD.",
fr. ft.
ww
Physical Address.City.Lid Zip
2T R£3YI YRIaS
O.11 1-740Ti
, Parcel Identification No.(PLN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: ,y
(ifw•cli field,one lat'long is suffieicnt) q
N
Signature fCerti ej well C atractor
Efate
6.ls(are)the well(s): nPermanent or ❑Temporary
Br•sioning ibis/orm..:'herehr rertifr that the­ell(c)was(were)constructed in accordance with
j to.NCAC 02C.0100 or 15.4 NCAC 02C•.0200 ff'ell C01tatructiotl Standards and that a corn
7.is this a repair to an existing well: ❑Yes Or ENO nfthis record has been prm'idrd to the xrll owner.
!('this is a repair.fill out knout well c•anstnrc»an information and explain the nature of the
repair under#21 remarks section or on he back of this farm. 23•Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Lou may also attach additional page,if necessary.
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
o p Geothermal Wells having the same (add'See Qcel iu Remarks Box).YoSUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple,ells list all leptlu if thfferent(example-3(�v200'and 2
40 24a. For All N'ells: Original form to Division of Water Resources (DWR).
10.Static water level below tap of casing:
(ftJ Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
�
If trufer level is abur-e casing.use."+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control( )
11.Borehole diameter 6118 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
Air Rotary 24c.For Water Su ly and O en-Lo0 Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county enx'ironmental health department of the county w here installe
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells pro'ducin 7 over 100.000 GPD:Copy to DWR,CCPCUA
PerinitProgram,1611 Ralalgh.
13a.Yield(gpm) I NS Method of test:
Air Lift MSC, NC 27699 16t
Chlor. Tabs Amount: 1 1/2 LbS
13b.Disinfection type: f
Revised 6-6-2019
North Carolina Department of Environmental Quality-Division of Water Rcsourees
Form GW-i