GW1-2022-01850_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: �y
Alfred Kiesling Sr 1 „' . /� ® @ 14�ixi rlfTiO .S
FROM TO DEWRCPTION ''nn
Well Contractor Name �t'� ; r�s 0 Yt ft.
2670-A FEB 16 2o22 L 6 C"ft.
ll
'rbrm seu.:
NC Well Contractor Ccnifiwtion Number
a� i�trr `e ��r ,�;m ' '' :�> �>uveai1�::
B & K Well Drilling FROM TO DIAMETER THfcKrN4 5 MATERIAL
p ft• 1 173 ft- 6 1/4 SDR-21 PVC
�3D3 ` FROM r0 DIA\1 E'fER ntIC1cN 7E55 MA rRl:\L
2.Well Construction Permit# ft in.
List all applicable we 11 coustructiot+p<mnits fi.e.UIC Co+mn'.State.L'ariance.eto./
ft.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER GLOTSIZE THI(XNESS MATERIAL
❑Agricultural
❑MunicipaLPublic ft ft m.
❑Geothermal(Heating/Cooling Supply) OResidcntial Wat;n-Supply(single) ft. ft in
❑lndusmal.Conuuercial ❑Rtsrd ent al
Water Su
pply P P1Y
(shared)
❑Wells> 100,000GPD FROM TO M\zEtuAr E�[Pr ACE�1E*T MECHUD&.4�IUUNT
❑Irrigation Nun-Water Supply Well: 0 ft- 20 ftB2fltOtllte POUF
❑Monitoring ORecovey ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groutdwater Remediation ;::Y9fi4fV9tGtta<YFf:::#!KG�:6f :>:�:x>:<:>•.;::::c<::«<:>:::::::;<»:<::<
OAquifer Storage and Recovery ❑Salinity Barrier FROM To AIATERIAt. EM Pt 4CEMFM METHOD
❑Aquifer Test ❑Stormw'ater Drainaae
ft. ft.
aL ft.
❑Experimental Technology ❑Subsidence Control .:..:.:...... :.: ...:..:.. .....:.
GGeothermal(Closed Loop) ❑Tracer
FROnt TO DESCRIPTIO\(color.hardness.sod/rock •gram sip esel
❑Geothermal(HeatinelCooling Retum) ❑Other(explain under#21 Remarius) ft.
ompleted:
4.Date Well(s)C
02 Z Well ft V fL r i /7
Ct. ft. s
Sa.Well Location: ft. ft.
FacilitytOwner Name Facility TD#(;fapplicablej
t L l ft. , ft.
Physical Address,City,and Zip
s
County Paz'ccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lono k wtficicntl 22.Certifica bn•/ -
K
Si°nat fCrnihed well Contractor are
6.ls(are)ffie wet!(s): �jPermanent or GTemporan -
Br si�nin�this long.!herel+t•rarrr/i:iiaar the+:rll!sl nzas(here/<rnsnvr+ed in orrnrdant•a n-irh
/s..r:VCAC 02C:1110n or 15.4 NC.iC 02C.0200 It'ell Coacstruction Standardscopy
and that a co
7.Is this a repair to an existing well: [:Yes or !]Noof this reenrd has been prm idrd rn rhr+:rll owner.
Lf this is a repair.ill our known well c»nstncction inforniounu and erpla6+the nutury of rhr
repair under 421 remarks section or on the back ofthis form. 23.Site diagram or additional,wen details:
You may use the back of this page to provide additional well construction info
9.For Geoprobe/DPT or-Closed-Loop Geothermal Wells haying-the same (add See�.� iu 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 TNSTRL'CTIONS
9.Total well depth below land surface: .S (ft) Submit this GW-1 within 30 days of well completion per the following:
For andripie nc11s list ell depths ijtGfferent(nt++nple-3(yC00'anti 2@!100') I
24a. For Allells: Original)form to Division of Water Resources (DIA'R),
10.Static water level below top of casing:40 (ft.) Wells:
Processing Unit,16'17 MSC,Raleigh.NC 27699-1617
If nvter IL+el is abo"e casing.use
6 1/8 24b.For Injection Wells:Copy to DWI_Underground Iniection Control(IUC)
11.Borehole diameter: 011-) Promam,1636 MSC.Raleigh,NC 2?699-1636
12.1iell construction method:
Air Rotary 24c.For Water Supp)y and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county entironmental health department of the county where ut.talled
FOR WATER SUPPLY WELLS ONLY: 21d For Water Welts producing Deer 100,000 GPD_
3/41 _Copy to DV'R,CCPCUA
13a.Yield(gpm) / Method of test:Air Lift mit Per program.1611 MSC.Raletgh.NC 27699-1611
13b.Disinfection type: C'hlor. Tabs 4mount• 1 1/2 Lbs
Revised 6-6-201A
1 North Carolina Department of En.ironmcntal Quality-Division of Water Resources
Form GW