GW1-2021-06523_Well Construction - GW1_20210809

zFCORD QW For internal Use OTilly:
WELL CONSTRUCTION RMO-Ji
1.well Contractor Information:
Alfred Kiesling Sr A4.:WATER 5'
FROM TO DESIC--- lox
Name ft. "0
2670-A
arm
r Certificaijon Number THICKNESS MATER1aL
NC Well CO"tl*actO FROM TO DW -TER
B & K Well Drilling Inc 0 ft. ft. 61/4 SDR-21 PVC
N :16 ANNER-6 M, 0.0R'.0B:M*;
Company!13me M.C.", MATERIAL
4f3 FROM .1.0 DIAMETER.
cition Permit N: _Q es'l — ft. ft. In.
Well Construction vic Co""y state.VaHa"C".dt.)
Lint all�pplic able well pariahs r'e ft. ft. in.
3.Well Use(check well use):
... ..... .....
..........
NI.ATILKIAL
FR-OiNI TO DIAMETER qtOTSIzE THICKNESS
Water supply well: O.MunicipaLtPublic
O.Agricultural a<�jdejjtial Wall Supply(single)
DGeothenrial(HCating/l Supply)
oResidential Water Supply(shared) iiL.: it 'T I
,
cindustrial!C01junercial FROl%I TO I&XIE EN Ll ET1IOV&NNIOUN7
01rdeation owells> 100,000GPD 0 ft- 20 ft- Bentonite Pour
Non-Water Supply Well:
ft. ft-
0MOnito.Ting ORrcovery
injection Well: ft.
(Groundwater Remediation
12Aquifer Recharge osalilliry Barrier Fill TO NIA ERIAL EMPLACFAIFAN
0 Aquifer Storage and Recovery oStormwaleT Drainare ft. ft.
t2Aquifler Test
E)F_Xperimental Technology OSubsidence Control
e,
necesaarit
........ ...
oc'eiatherinal ❑(Closed Loop) OTracer FROM TO l)FqC.RjpTlON in rat,I,-I
-1—bitri it,
tl
cGeothermal(Heatin.jCooling Return) ClOther(explain under#21 Retnarl_%) I ft. ft. 4
ft. ft. 0
4.Date Well(s)Completed: Well 1D# ft. ft.
'il: /? Al
r
,a.Well Location: ft ft.
6
fc. ,ft
Facility ml�(ifaPplil _j't25__ L
ft ft.
Faeility,Owncr Naire f.E�:
-ft. -ft.
Physical Address.City-a4zip
7bElYtaRhS
-pucelldentification No.( LN
County degrees:
5b.Latitude and longitude in degrees/minutes/seconds or decimal22.Certification:
ififwcll field,one lat!ltin.-Ms*ufficicnt)
N -W f4 —is
6.Is(are)the well(s): nPermanent or oTemporary (i�gp4aate of CImnified Well 4ont-ractor
I/ i
that he,vill(s)was(ivrril)eonsuvrtrd in a,t-ordani nirh
1 i.4..VCAC or 114,Vek 02C.n21ln wen CojLqtml 51andids and till cqvy
7.is this a repair to an existing well: CYes or orihis record has been provided to the
rtl owner.
!(this is a--repair..' -a fill out kh well consiniction 40-01i"a,id el the nature rij
repair i di t real section or u),the back of this form. 23.Site diagram or additional well details: struction info
You may Use the back of this page to provide additional well coii
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional Pages if necessary
construction only I GW-1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drillel
Submit this GW-1 within.30 days of well completion per the following-
9.Total well depth below land surface: -3 '5 —
3(qc.00 "tit
,1�ffrj-ent(e.vi sources (DWR),
Forandripit,1-1/s list It""i"P'" . 24a. Far AJU Wells: 0171*10al form to Division of Water R�,
10.Static water level below top of casing:40 (ft.) Raleigh-NC 27699-1617
Information Processing Unit,1617 MSC.
""ter level is above casing.use 24b.For injection We Copy to DWR-Underground Injection Control(rUC)
61/8 NC 27699-1636
11.Borehole diameter: Program,1636 MSC..Raleigh
Air Rotary 24c.For Water Supply and ID Geothermal Return Wells:Copy tothd
I,Geothermal
-
12.Well construction method: county en-,;ro,ninerital hea.1111(lepaTIMUMt 0 the ounty where instil—ed
(i.e.auger,rotary.cable,direct push,ate.)
too.000 GPD:Copy to DWR.CCPCUA
24d.For Water Welts producing_o, r
FOR WATER SUPPLY WELLS ONLY: pellnitprog-ain,1611 MSC.Raleigh.NC 2/091)-10 1 1
Method of test:Air Lift
13a.Yield(gym)
Chlor. Tabs 1 1/2 Lbs
113b.Disinfection type:. Amount:
North Carolina Deparuncrit of En%ironmi Quality-Division of Watir Resources Revised 6,6-201 A
Form GW-I