GW1-2022-03895_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD
For Internal Use Only:
1.well Contractor information: ......
Alfred Kiesling Sr 14...w FROM TO DESCR I TPTION
Well Col]tTZCtOT Name
2670-A
...013C.
V. InttnuttiAcm 3AN
NC Well Contractor Certification Number THICKNESS MATERUL
FROM TO DUMETER - -21 PVC
B & K Well Drilling Inc 0 ft. P7 0 ft- 61/4 in SDR
.-' rin MATERIAL
Company Name FR.OM NLR DixytETE 4 N E'S S
2.well construction Permit ighi ii L
LTIC,Colairv.State.Variance.&W) ft. in.
1,.vt all applicable well 01&truction perinits, in.
3.Well Use(check well use)! NIATERIAL
C
FROM TO, DIAMETER SLOT SIZE THI
Water Supply Well: 0mu-nicipal/Public ft• in.
oAgricultural Water Supply(sill 5-ld) ft. in.
OGe I 6therm.al(Heating/Cooling supply) 21P esidential W
01ndustrial!Collullercial OResidential Water Supply(shared) 18s.GRi1IIT
ENIPLICE. ENTMErHOD&,2I2u2-
Dwells>100,OOOGPD FROM 0 I&MRIAL
Recharge Dirri-ation ❑
0 ft- 20 ft- Bentonite Pour
Nun-Water Supply
Nun� ater Supplv Well:
0\401litoring oRccovcry ft. ft.
ell.
Injection Well: X:'
f 06roundwater Remediation
CaKAY
DAquifer mxTER Al. Mpt&rVNIENT METHOD
a Storage
OA ifer Storage and Recovery ciSahitiry Barrier FROM TO
qut ft.
C Aquifer Test oStormAater Drainage
fc fit.
DSubsidence Control X".
oExpelimental Technology .......
oTracer DESCRIPTION(20101 hardn illrm Bin�fte.etc DiGeothermal(Closed Loop) FRO TO
DGeotbermal(HeatingiCool(ng Return) E30ther(explain under#21 Remali-1) ft. o ft. CUD
ell fD# ft. 0
4.Date Well(s)Completed_lcp_�V
ft.
ft.
Facility TD#(ifapplicable)
Facility/0-ner Name ft. ft.
ft.
Physical.Address,City and zip
CIQ 3
palccl Identification No (PIN) 11?411L I"'kA
County
vrI
5b.Latitude and longitude in degrees/minutes/seconcis or decimal degrees-
(if well field,one latflong kg.utficicnt).N ce�nifi 1, n IDat
Signature e ell Contractor
6.1s(are)the well(s): APermanent or DTemporarviedinaccordance sere onsn %vith
I' Co,Lviruction Standards and that a corn5. CO2C.010t)or li.4 N.C�CO2C.0200 11
1.Is this a repair to an existing well; c:,Yes or nNo ofihi�record has been providedto the Yell orvner.
it this is a repair.'fill out known well on.vinnon infannorin),and plain the noral rhe additional well details:
i-epair under#21 rernarkc section or on the back of this fioml. 23.Site diagram or ad
You may use the back of this page to provide additional well construction info
9.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.
tv I GW-1 is needed. indicate TOTAL NUMBER of wells
construction.on 24.SUBMITTAL INSTRUCTION
drilled:
9.Total well depth below land surface: . 41 AJ S5_ Submit this G'w-i within.30 days of well completion per the following:
For andliPle wells lisialldepilts-it different
(ea-ainple,3(�,COO and 2@!1001
24a. For All Wells: Original form to Division of Water Resources (D\VR),
10- casing:
40 tft*) Information 9 U �,1617 MSC,Ralei--h-NC 27699-1617
Static water level below top of — Processing rut I -
(jl
­'ter level is above cosing.we'*+ 24b. Copy to DWR_Underground injection Control(ITJC)
6118 (in.) C Raleigh,NC 27699-1636
1.Borehole diameter: Program,1636 MSC, .I Return Wells:Copy to the
12.Well construction method:Air Rotary 24c.For Water !h)�a!!n department or the county_.."installed—
to Ii ent!
(i.e.auger,rotary.cable.direct push,etc.) couni�eml I hearth
I p
FOR WATER SUPPLY ONLY: 24d.For Water Welts roduci ,over 100.000 GPD:Copy to DWR,CCPCUA
Method of test'.Air Lift permit Program.1611 MSC,K
13a.Yield Om) I i;;�-=Chlor. Tabs Amount: 1 1/2 Lbs
13b.Disinfection type- —
Revised 6-6-2019
Nonh Carolina Department of En,ironmcnial Quality-Division of Water Resources
Form GW-