GW1-2021-06524_Well Construction - GW1_20210809

WELL CONSTRUCTION REC0RPA9_W_-_11 For Internal Use Only:
1.Well Contractor information: :77
Alfred Kiesling Sr 10
FROM TO DECCRI PTION
Well Contractor Name
2670-A
B & K Well Drillin NC Well Cc�jln,,Ctor Certification Number C� rm U-N-
FROM DWNIETER THICKNESS MATERLAL
g Inc 0 6114 SDR-21 PVC
IS -
Company Name ER G*%NG'1.0 DIAMETER UBE N G THICKNI�SS MATERIAL
2.Well Construction Permit /V A FROM ft. ft. in.
List all applicable well C011stru"'O"permits(" L!'C'Colully Variance.ere.j ft. ft. in.
3.Well Use(check well use):
aterSupply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural oMunicipal/Public ft• fL
CGcothcrmal(Heating/Cooling Supply) *esidential Water Supply ft
.. .........
C-Industrial!Conutiercial Okesidential Water Supply(shared)
DIrrigation. D Wells>100,000GPD FROM I MIT R1
0 ft. 20 ft- I Bentonite JPour
Non-Water SuppIV Well: —
0mollitoring ORccovcry
Injection Well:
OAquifer Recharge ClGrouadwater Reniediaiion
[Aquifer Storage and Recovery [Salinity Barrier ITU MATERIAL EMPLACV11ENTME]HOD
CAquifer Test oStormwater Drainace
OExperimental Technology CJSubsidence Control
[Geothermal(Closed Loop) OTracer ssary
FROND RIPTT 101 h-TO DE�CON(­ est.soil'.Wk n me.etc
oGeothermal(H (explain under#21 Remarks)
'1
.1 .. ft
4.Date Well(s)Completed Well ID#
ft
Sa.Well Location:
—Ild ei-
Facility,'OwnerNayne Facility M#(if applicable)
ft. ft.
Physical Address,Cityland Zip
't7777777777��
County NLccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(it'well field,one laVlong k sufficient) 22.Certification:
N -W
Sietiat
fC'rrlue'.Well� tract Date
ni Jec,Well Contract
6.1s(are)thewell(s): nPermanent or OTemporary Arsigning th&.1b)-m.lheehi.cet-66:rho,rhe,:rll(s) vas(were)ronsiruc-tedin at.-ordance with7.is this a repair t.o an existing well. [Yes or IoNo 15ANCAC 02C.010il or 15.4 X'C'ACO2C.1720f)well colloruction Standards and dwr a eop_,•
i
ffrhis is repair.fill out known-ell,6n.11J1?VJ_itifrn otolin"07 lair the nature n.I'the
of this recnrd has bren provided to fho xrll owner.I-epairriitderr*21remarks,�e.c.iioisoronilieb.ckq�!;,is.fo-1- fey" 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Geoprot),e/DFT or Closed-Loop Geothermal Wells having the same (add'See O\-cr'in Remarks Box).you may also attach additional pages if necessary.
construction.only I GW-I is nceded. fridicatc TOTAL NUMBER of wells
drilled:__ 24.SUBMITTAL INSTRUCTIONS
Submit this GW-1 within.30 days of well completion per the following:
w land surface:9.Total well de land surf
For naltriple W015 list all'IePilu if different(iatunple-3(C"20 and 20001
24a. For All Wells: Original form to Division of Water Resources (DWR),
I o.Static water level below top of casing:40 Information Processing Unit,1 1 617 MSC.Raleiab.NC 27699-1617
II-11tep level is tibat-e casing.use— I
61/8 24b.For Injection Wells:Copy to DWR,Unden-nound Injection Control(IUC)
11;Borehole diameter: (in.) Progam,1636 MSC,Raleigh..'i NC 27699-1636
12 Well construction method.Air Rotary r W d Open LoopGeothermal Return We!1L1S_Copy to the
24c.Fo Water
Sit
(i.e.auger,rotary.cable.direct push.etc.) county en%-iro­nm,:nPe1!hL,!1!t!h department of the county wncic­Ied
FOR WATER SUPPLY WELLS ONLY: 24d. Copy to DWR,CCPCUA
ii Air Lift Permit Program,1611 MSC.Raleigh.NL 2I699-1611
13a.Yield(gpm) l Method of test
1
Tabs Chlor. 1 b
13b.Disinfection type: Amount: /2 Ls
Form GW I F,vised 6-6-2019
,North Carolina Department of En,ironnacrial Quality-Division of Water Resources