GW1-2021-07292_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD G'AZU, For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr 4YATRRZONES
,,. .....
J'` FROAI TO DESCRIPTION
Well Contractor Name �rN JaSft. 11. �© ,�3
2670-A y-
o 02. 0 v2
t0 r10
NC Well Contractor Certification Number ^�n•�p,, 15 VUTER. A51NG:far.:mutti cased*ells.•DR' NER' E' Iiealile
B & K Well Drilling Inc t?�` 1_J FRODI TO DIAMETER THICKNESS MATERLAI
0 ft- 6 1/4 '" SDR 21 PVC
Company Name �N�
\Q 1&i'INNER G iSING OR:Ti1BLNFr. i otheiitYat dosed loG'
2.Well Construction Permit#:_S S� I 3 1ROnl r0 DIAMETER in. THICKNESS I MATERIAL
List all applicable well Construction perinits i.e.UiC',C'oroav,State.variance.etc./
ft. ft. in.
3.Well Use(check well use):
1:7.:SCREEN :<
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R, I in.
❑Geothenmal(Heating/Cooling Supply) *Ksidential Water Supply(single) ft. ft. in.
❑Industrial!Conunercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MAATERIAL 'EMPLACEMENTMETHOD&AMOUNT
Nun-Water Supply Well: 0 ft. 20 't Bentonite Pour
❑Monitoring ❑Roeoc•ey ft. R.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation ir?SAN#)lGRtv�[ P4GlGGf livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control tt. R.
❑Geothermal(Closed Loop) ❑Tracer 49 7)R1LLIiVGLOG.8ttactlaittiifiltialsBeetsSt:necessary:: ...
m size•etc 1
k e, a
❑Geothermal(Heating/Cooling
Cooling Return) ❑Other(explain under#21 Remarks) a TO DESCRIPTIONcolor hardness,sod/rge
I. ©a. eta 1
4.Date Well(s)Completed:a,�s� Well ID# /�-0 ft. ` ft' /t Ouch/ 0 t
5a.Well Location: ft /if ft v h A -0 1
�
ft. Vn ft. r� �1� flDrr,irs
Facility ID#(if applicable) 0 ft. ft. .i'
Facility/Owner Name
0
ft. ft.
Physical Address.City,and Zip
7,6 (
t�(.11 ►G,�SB' a d � r� 21<ibE147ARItS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W
ature Certified Well Contractor Date
6.Is(are)the well(s): d ❑
Permanent or Temporary -
Br signing this torn.l herehr rernhi that the icel!(s/arts rm)consnuc•ted in accordance kith
7.is this a repair to an existing well: ❑Yes or DNo 15.4 NCAC 02C.Olon or 6.4 A'CAC 02C.n200 bell Comtruction Standards and that a Colt,
Lf this is a repair.fill out known well can inaction infnrinaami and explain the nature of the of this retard has beenprovided to die well owner.
repair Larder#2I remarks section or on the back of this form. 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-Loop Geothermal Wells haying 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
drilled: 24.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For inuttiple irells list all depths if different(example-3(ai_00'and 2Ciig00)
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.Raleigh,NC 27699-1617
!(hater level is aboxe casing,use'+
6 1/8 24b.For Injection Wells:Copy to DWI_Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable•direct push,etc.) county environmental health department of the county where installed,,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GEL):Copy to DWR,CCPCUA
r� Air Lift Permit Program,1611 MSC,Raleigh.NC 27699 1611
13a.Yield(gpm) t� Method of test:
136.Disinfection type: C'hlor. Tabs Amount: 1 1/2 Lbs
Fonn GW-i North Carolina Department of Ens ironmental Quality-Division of Water Resources Re iisod 6-6-201R