GW1-2022-03899_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORDEGA-1 For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr '4`1%1
TO
FROTI ..DEtCRfPTION
Well Contractor Name ft ft.
2670-A ft, p -tt•
NC Well Contractor Certification'`lumber 1-�-Y:).t}TEite Et'u
at+le
FROM I DIAMETER THICKNESS MATERLAL
B & K Well Drilling Inc 0 ft. ft. 6 174 in SDR-21 PVC
Company Name :11yNEIta~•' OR:?E[3SY�TG:-'eotheimal'etossd-l- ?'
(�, / F'KO�I to fL DIAMETER 1'HICKNKSS MATERIAL
2.Well Construction Permit tJ: }� ft in.
List all applicable well construction per+nits I.c.U!C',Cororrv.Stare.i�nruenie.¢tc.l Ct. in.
ft.
3.Well Use(check well use): 1.7::SOMEN
Water Supply Well: FROM ro
DIAMETER CLOT SIZE THI(KNES11; CRIAL
❑Mtmicipal/Public
ft. ft. tn.
❑Agricultural
❑Geothermal(HeatimLIC•ooling Supply) [nResidential Water Supply(single) ft ft.
m
❑Industrial/Conuuereial ❑Residential Watdr Supply(shared) 1gs.GTt0III -'
❑Wells>i(111,WUGPD FROM TO MATERIAL EAIPLALErtENTMETHUD&ti1tUUNT
❑Irrigation 0 ft. 20 ft. lBentonite Pour
Nun-Water Supply Well:
❑'Monitoring ❑Rccoccry
Injection Well: ft tt.
❑(irouuwa dter Reniediation !e
❑Aquifer Recharge 19SANl0iGR3��Lt'• �"' EMrtAcenlElvTMETHOD..
❑Saliniry Barrier FROM TO MATERIAL
❑Aquifer Storage and Recovery ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Subsidence Control tt ft.
❑Experimental Technology
❑Geothermal(Closed Loop) ❑Tracer ? : . DESCRIPTION(c0I-1 t1ajn,,& r.,k e*amr:e«e.t
FROM TO
❑Geothermal(HeatinJCooling Return) ❑Other(explain under#21 Remarks) ft, " ft. gay
R. �?cS- ft.
4.Date Well(s)Completed:SZ-Well ID#
ft. ft. r!/
Sa-Well Location://fir ft. Ct.
ft. ft
C
Facility/OwnerNa,nt Facility M#*(if applicable)
,/
14v h fr. ft.
alt., �. " rr.e �Y �' APR I
ft. fr.
Physical Address.City;and Zip Zl:RE3}InR)t$.
Parcel Identification No.(PIN) r r 1 ra n
.�
County �.,., ),c._tiil.a Ir rat
51b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: !2.Certifca "(ifv•cll ticld,one IaUlono is sufticicnq ^ ^/ \��
N W (C�
Sie_nature fCeni red Well .ont actor Date
6.is(are)the well(s): nPermanent or ❑Temporan
Bu srening rhis term.1 here!.'craili that the i:rl/!s/w were)rnnsuvrred in accnrdm,<•e n•irh
I SA NCAC 02C.070n or 15.4 NCAC 02C.n200 Krell Contrruction Standards and that a cam,
if this
this a repair out
a n trusting well: Gies or d explain
of this recnrd has been prorided m the v.rll os.ncr.
!!rhis is a repair.fill nut knaaa well cnnslnrcrion infonnminn and etplain the nnrarr nfrhr .
repair rorder#21 remarks section or on the back oftlls farm. 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'See Ovee in Remarks Box).You may also attach additional pages if necessary.
construction. ly 1 GW 1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: &19 5, ._(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple It l/s list III depths if different(eaainple-3(ai_00 and 2(dll001
24a. For all Wells: Original form to Division of Water Resources (DH'R),
10.Static water le-.el below top of casing:
40 (ft.) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
fj'uvter lest/it abort eosin_.M<e' "+
6 1/S 24b.For Infection Wells:Copy to DWR.Underground Injection Control(I )
Ii.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 entironmental health department of the county a here to tolled
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producing over 100,000 GPD:Copy to DV'R,CCPCUA
Permit Program,1611 MSC,Raleigh.NC 27699 1611
13a.Yield(gpm) O Method of test:Air Lift I.
13b-Disinfection type:
Chlor. Tabs Amount: 1 1/2 Lbs
Revised 6-6-201 R
North Carolina Department of En.ironmcmal Quality-Division of Water Rcsourecc
Form GW-1