GW1-2021-08000_Well Construction - GW1_20210809

A �
WELL CONSTRUCTION RECORD(GW-1) (or internal Use Only:
1.Well Contractor Information:
„ :.: ..:....:..............;v::>;::�:::::�;�::;i;a.;is�:i?:'::i�:::<;i:;isi>.;i:its.';::;:i;<`�:+:.:£>i3i::,iiiii:ii:i:'i:
Alfred Kleslmg Sr 14 Vi:A7 170?!Il S<::
FROhI TO � DESCRiP'rT0\
Well Contractor Name
2670-A �o tL -?--fr. fig/ F u�R0
NC well Contractor Certification Number ;,1Erx:F)F1'FERa`.i:Si drm K`
B & K Well Drilling Inc FROM TO DIETER THICKNFSS MATERLtI
AM
0 ft, ft. 61/41. i° SDR-21 PVC
Company*tame ?631!�1£R tBEBS.LvIE`.'eeXhesmafctasedr '
7 FROnI •10 DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: a 3 V (t ft. m•
Lisr all applicable well cotcsrruction permits i.e.UIC',Cotutnv,State.P%2riance.etc./
R- fr. In.
3.Well Use(check well use):
.
Water Supply Well: FRONT TO DIAMETER CLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
Geothermal(Heating/Coolin Ke
g Supply) Fsidential Water Supply(single) e. tt. 1°•
❑industrial/Conuuercial ❑Residential Water Supply(Shared)
€t�ltflf3 F .i>
❑Irrigation ❑Wells>100,000 GPD FROM TO MIIERIAL E tIPLACEAIEPT MEIHUD&NAIUUNT
Non-Water Supply Well: 0 ft. 20 ft. B6ntOnit6 Pour
❑Monitoring ORccovcry
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO h1ATERIAI, F.MPL.ACEMENT METHOD
CAquifer Test
OStormwater Drainage
OExperimental Technology, OSubsidence Control R. tc.
❑Geothermal(Closed Loop) ❑Tracer 3�::BRil LlNG4G'sttseii; zxdshsheeEe3£erv;::>:?«3»:31:::%;[:»>:>;>:i:>:>;:<::r::;;:
FROM TO DESCRrPTiON(color.hardness,soiVroaek gin sizes etel
OGeotbermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D R. , /0 ft.
4.Date Well 7 s)Completed: a� .?/� Well IT)# tZ 1 4 D W
ft.
V ` t oN
5a.. q Well Location:: ft ) fr.
VAT n�1f1�`s �1` ft. fr-
Facility/OaTerName Facility (ifapplicable)
Ob
ft. ft. �9
1 t r ft. K
steeI Address,City. Zip -
:
;ZL
County Parcel Identification No.(PIN) ` 6-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (10 5,_
(if well field,one laa'long is sufficient) 22.Certification: I
R ?r
Signature o ertitied ell Con erne Date
6.ls(are)the well(s): nPermanent or ❑Temporary
Br signing this farm.I herehr rer nha that the t:-ll(d,vas sere)ronsrructed in artordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15.4.VCAC 02C.0700 or 15.4 NCAC 02C.0200 lVell Construction Standards and that a eoM-
ofthis record has been provided to the vrll owner.
11'rhis is a repair.Jill our knoM�n.well cnnctrraaion infarmmimr and explain the nature nl the I
repair under 421 remarks section or on the back of rltis-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 having the same (add,Sze 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: 1 _ 24.SUBMITTAL INSTRUCTTONS
9.Total well depth below land surface: S (ft.) Submit this GW-1 within 30 days of well completion per the following:
Fur multiple reeds list all depilu-if&fferent(Trample-3(at_00 antt'idi100)
40 24a. For All Wells: Original]form to Division of Water Resources (Dw'R),
10.Static water level below top of casing: (ft.) Information Processing Unit,16',17 MSC.Raleigh.NC 27699-1617
if outer level is abut-e casing.we-'+"
6 1i8 24b.For Injection Wells:Cop R,y to DW 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 en�ironmenral health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells product over 100,000 GPD:Copy to DWR,L'CPCUA
T Permit Pro,,am,161 l MSC,Ralcrgh-NC;27699-I6l t
13a.Yield(gpm) U Method of test:Air Lift
13b.Disinfection type:ChIOr. Tabs Amount: 1 /2 LbS
f
Revised 6-6-201A
Form GW-1 Nonh Carolina Department of En,irotrmcntal Quality-Division of P'arcr Resources