GW1-2021-04683_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1 l For internal Use Ouly:
1.Well Contractor Information: P
Alfred Kiesling Sr »- N', =ar=.aao
FROM TO DESCR PTION ;
Well Contractor Name b ft. eQ ft. ze
2670-A MAY 21 2021 J�f ��t 1 !
NC Well Connaetor Certification Number
I n ,�r► 3 r era ' ivelS
r)rnr � FROM TO D1 � TER .Ol2LENF;SY' .:.M.sAfilTeE'.RAL
11 I✓
B & K Well Drilling 5-^i:o1 i .
0 ft. q_5 ft. 6 1/4 SDR-21 PVC
Company Name 4,I1N1}11rRG1C;13RlTTBF1G eox3teimblcCdsetl= }
✓ Jal - o r� FROM 7'O UTAMErER THICKNESS MAI ERI�I
2.Well Construction Permit#: j �n ,0 O (� (t ft in
List all applicable well rotutruedou permits+.e.L71C'.Co+u+ry.State.Forianei, etc.)
in.
3.Well Use(check well use):
.. _.......... L -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS :MATERIAL
❑Agricultural ❑lvlunicipal/Public fL
❑Geothermal(Heatin_g/Cooling Supply) Or6sidential Water Supply(single) R. ft in.
Olndus[nalConunerciat Resrdenu'al Water Su
pply
P1Y
(shared)az ed
)
i0�3`tl��s3i%<ii;i;ii `<i:<iiiiti::�i�:;`:�:;cis:.'F :.iy >f,J,✓,ii�i%'<'izii2;2c;;i;;>:::pis:i<;:2:;<;:s:;:;:::,:..
[]irrigation ❑Wells> 100,000GPD FROM TU K1,TERIAL El%PLAC _T AWL BUD&AMOUNT
Nun-Water Supply Well:
0 tt. 20 tt, Bentonite Pour
❑monitorin. ❑Recovery
Injection yrrell:
❑(irouudwater Remediation -
❑Aqutfer Recharge
V.fi41V8?Gi2dYL 134Ci4 Ff lscable)..
❑Aquifer Storage and Recovery ❑Salinity Barrier FRON TO h1ATF.RIAL EMPLACEMENT M RTHOD
i
❑Stormwater Dranace
CAquifer Test -
ft. ft.
❑Experimental Technology ❑Subsidence Control
............::............. .....
❑Geothermal(Closed Loop) ❑Tracer 26;73R11 tiitrGLOG attackattrflaFsii3tlecexiatr
FROM TO !u EscRIPTIox wi—hardn IV rack in size.etc.l
❑(jeothermal(HeatinJCooling Return) OQtlter(explain under#21 Remarks) ff• {O ft.
4.Date Well(s)Completed: 3 oZ Well ID#
o rt, 9,5
b ft. �J��t,�/ p L
Sa.Well Location- ft ft-
Facility TD#(if applicable)
Facility/Owner Name tt• l� ft' �Xr2 _
[' ft. ft
tirli c�•`e� C 1tw�ti���OY+� Q`� r ft. ft.
....:.. :::::'::::;7::::::.:J...•:,r.; i7�:iG�>r:i':i:G %'%<'>;??:i::::5:::y:
Physical Address,City,and Zip
O b d
County pal, Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la61ong is sutiieicnt) 22.Certification.
N W S Z
ignat a of Cenified Well Contractor Ir Date
6.Is(are)the well(s): nPermanent or ❑Temporary
Br signing this 16tnr.!herehr rerti/i that the,:—ell(s)was(were)cauuvrred in accordanceuirh
/s,t.VCAC o_'C.0100 or 15.1,CAC 02C.010n Tfrell Construction Standards and that a cqM
7.is this a repair to an existing well: ❑Yes or �JNo orthis recnrd has been prm'ided to rhr arll owner.
11 rha is a repair.fill out known well rnnslnrctian inranna+inn m+d explain the nature nrrhe
repair ender t21 remarks section or on the back ofzhis form. 23.$ite 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 Over in Remarks Box).You may also attach additional pages if necessary.
construction-only i GW-1 is ncedod. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
i_
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
Fur n+ulriple it-ells list ul/depilis i(difrerent(example-3(al200 unit_@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft) Information Processing Unit,1617 MSC,Raleigb,NC 27699-1617
If+cuter level u•ahu+•e casing.use•'+
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
]2.Well construction method:Air Rotary 24c.For Water Supply a al Return Wells:Copy to the
'and Open-Loop Geotherm
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the county ufiere ms*alled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over I00,000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Prey am,1611 M. Raleigh.NC 27699 1611
13a.Yield(gpnt) Method of test: .l 1 I
13b.Disinfection type: Chlor, Tabs Amount 1 1/2 Lbs
j
` Rcviscd 6-F-20i>s
Form GW-1 North Carolina Department of En%iroomental Quality-Division of water Resources