GW1-2021-07288_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: v.,
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�' �L— ;. ACAS?.ATE&Z41!TES:.::i:::.>:.;:.<: :.: ;,.:,,:,...;.;::;:
Alfred Kiesling Sr r��", �r, To DESCRIPTION
Well ConttactorName
2670-A
NC Well Contractor Certification Number P t p�G 15 Yilf FEIt nr.:mtilii cli9i d'wel>s :E)RHICKNESS 3 ll�tl MATEnkt,
n C3 FROM TO
B & K Well Drilling Inc _��,�� 0 ft. -Tt. 6 1!4 SDR 21 Pvc
to
rt v
etller
Company Name DIAMETER s 26:IN lERGkSINIt.f31 I1BL`Tm: 'em E`clt,sed loe
q M'ROnI '1'O 'THICKNESS MATERIAL
2.Well Construction Permit#: y ` ft ft• in.
List all applicable well Co+nsrrurtion permits+.e.U('.Cotmrv.Stnte.➢ariance,e1C•) ft- R• in.
3.Well Use(check well use):
%I FR.FR f1 EN.3:
Water sUQQIy Well: O�1 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M 'cipaUPublic
tt. fL in.
esidential Water Supply(sin le) ft. ft. in.
❑Geothermal(Heating/Cooling Supply) PP y g
❑Residential Water Supply(shared) %:1$i?uRf1I3E. : -
❑lndustriaUContnrrrcial FRODI TU DL>,TERIAL EMPLACE?•tE)\TMETHODsc.AI(tUUNT
❑Irrigation OVJells>I00,000GPD 0 R 20 ft-
Bentonite Pour
Non-Water Supply Well: ORccocery ft.
❑Monitoring
R.
Injection Well: ft ft•
❑Groundwater Reniediation
..LA:SANS,'GitdvEL;PaGKfff....... btel.. ..
❑Aquifer Recharge MATERIAL
FMPI 4CF,(IENT MFTH(10
❑Salmi Barrier FROM To
OAquifer Storage and Recovery ty it. ft.
❑Aquifer Test ❑Stormwater Drainage
❑ExperimentalTechnology
❑Subsidence Control
OTracer 7h:T3Tti# 1)NGtOG' iGtcheddifiiAalShee--r h rtingm
❑Geothermal(Closed Loop) FROM TO DESC.RIPTIO�(oobr nardn:s gu r«k G ^�_�n�•I
❑Geothermal(HeatineJCooling Return) ❑Other(explain under#21 Remarks) ® ft. �r ft• 1/P
ft. OL/ i
4.Date Well(s)Completed: Well ID# ' v
ft. ft.
5a.Well Location: ft. R.
v
ft. ft.
Facility/Owner Narne Facility iT);(if applicable)
e� 1/ ft.
Af feal�l 1 �� ft. ft.
................
Physical Address,Uty,and Zip
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '12 Certification: r
(if well field,one Iattlong is sufficient)
N W 1✓t� �
Sienature o errified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporay
By signing this lnrnt.l hereby rer•tifi:that the r:wl!(s)i (were)ronstru(,red in arr•ordnr+ra w•id+
13A NCAC 02C.0101)nr 15A NCAC 02C.0200 Well Couuruchon Standards and r/ t a co
7.Is this a repair to an existing well: ❑Yes or ONo ({Y
o/this record has bren provided in rho r.rll owner.
!l this is a repair.fill our knoun well rnnSinaaimt infnnnatinn and explain the nature gjrhe
repair under#21 remarks section or on the back of this/ornt 23.Site diagram or additional tell 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 Ovee in Remarks Box).You may also attach additional pages if necessary'.
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells24.SUBMITTAL INSTRUGTiONS
drilled: /
9.Total well depth below land surface:
_(ft.) Submit this GW-1 within 30 days of well completion per the following:
Fur n+uMple+tells list all depilu if di•(Ierem(Trample.-Agt2,00'anti @J00')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
(ft-) Information Processing Unit,'1617 MSC.Ralei--b.NC 27699-1617
/(rioter level is above casing.use"+"
6 1/8 24b.For Infection Webs:Copy to DWR_Underground Injection Control(IUC)
it.Borehole diameter: (in-) Pro,am,1636 MSC,Raleigh,NC 27699-1636
Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
1.e Well construction cable,
method: county environmental health department of the county where installed
(i.e.auger,rotary.cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over too.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Proms tot,1611 MSC:Raleigh.NC 27695 I'll 1
13b.Disinfection type:
Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Enrironmcntal Quality-Division of Watcr Resources I
Revised 6-6-2019
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