GW1-2022-03900_Well Construction - GW1_20220412

' For lntemal Use Only:
WELL CONSTRUCTION RECORD(GW-1)
1.Well Contractor Information:
Alfred Kiesling Sr
FRODI To' DESCRIPTION
well Contractor Name ft. ft,
2670-A SpfL D L
/2�G�"U✓LG S.. .
NC Well Contractor Certification Number 7:f63f,FROM CEReTO Set miDLA: sEeTtfE�Rc clts;E)THICKr�E' f
MATERLAL
6 & K Well Drilling Inc 0 ft. ft- 6 1/4 I° SDR-21 Pvc
Company came %4NNERCAS1NG K'XUB Il' eutlieicnaf
0 etoscd loe 3<:
3cp r Y d�/ FROM 10 i"
DIAM rER l'HICKhhS� MAlhR11L
2-Well Construction Permit#:
ft tx.
Lisa all applicable well construction pennies Le.017.Cotauv,State.hanance•,et4./ ft• in,
ft.
3.Well Use(check well use): t:7.:St71ELtl!? .
Water Supply Well: FRODI TO DIAMETER SLOT SIZE THICKNESS `MATCHIAL
OAgricultural ❑MunicipaUPublic
f[- f L in.
.
m
/ a sidential Water Supply(single
GGcothennal(Heatin_Coolnl,,Supply)
PP Y ) rt- R•
0lndustrial7Conunercial ❑Residential Water Supply(shared) lg;iti1t01�f .; -
❑Wells>l UQ000 GPD FROM TU MATERIAL E�IPLACE�IE�T METHOD&.ti�tUUNT
❑Irrigation 0 rt- 20 It- Bentonite Pour
Nun-Water Supply Well: ft ft.
❑Monitoring ❑R"ovcry
Injection Well: tc ft.
❑Groundwater Reniediation k
LAsSAtVBlGR3NF1.Y.KGi�&f
pAquifer Recharge M,ATERIAI FMPI.ACEMEWT METHOD
❑Salinity Barrier FROM To
pAquifer Storage and Recovery g• ft.
OAquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control -
S 1)It1#LiEVG;LOG atacb'"' &66iWlihee!§N'ntces+er•;>
❑Geothermal(Closed Loop) FROM TO DES- [PTIO\(color.hardness,soil k tram size SEE;
❑Tracer
OGeothermal(HeatinJCooling Return) ❑Other(explain under#21 Remarl.S) ft ft. r— l
�l/��j 10 ft. O ft.
4.bate Well(s)Completed:� J��'� — Well rD# r V
Sa.Well Locatio ft. 0 ft. j=
ty-/Ihweyner Name Facility M-1(ifapplicable)
Facili
�t o fr. ft.
ft. ft.
Physical Address,City;and Zip
t//y a6 Am II l lklrllqw
Parcel Identification No.(PIN) ...
County
5b..Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,2 Certifrcati n
(ifwell field,one lat/lona is sutlicienq / y ^
r W
mature Cenitied Well Con ctor
Date
6.Is(are)the well(s): Permanent or ❑Temporan -
Br signing,this fnrm./W ell C rertr'M that rice l!s),ens(were)ronsuvrted in a4rardmu•e,rith
7.is this a repair to an existing well: ❑Yes or 'JNo
1 s,a:YCAC 02C.0100 or I S.a NCAC 02C.0200 If`e/l CatLtI motion Standards and that a copy
of this record has been pr o,ided rn(he vrll o wer.
If this is a repair.fill out known well rnn,ctngaian infonnatn and explain the nature nt the
repair under 421 remarks section or on the back ofthie formia. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or.Closed-Loop Geothermal Wells having the same (add'See Over it,Remarks Box)!You tray also attach additional pages if necessary.
construction.only 1 GW-i is needed. Indicate TOTAL NUMBER of wcllS 24.SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: t�LC Submit this GW-1 within 30 days of well completion per the following:
Put multiple wells list all r/epilta iii dtfferertt(rrnmp(e-9(cL'0n'Intl_'(d!1001
40 24a. For ?Ill Wells: Original form to Division of Water Resources (DW'R),
10.Static water level below top of casing:
(ft-) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
1l,,,fret level tr aha,e casing.wr"+" 24b.For Injection Wells:Cogy to DWR.Underground Injection Control(IUC)
11.Borehole diameter:
6 1/8 (in.) Prog m,1636 MSC,Raleigh,NC 27699-1636
�_
Air Rotary 24c.For Water Su ly and O I en-Loo Geothermal Return Wells:Copy to the
12.Well construction method: county emironmental health department of the county where in talied
(i.e.auger,rotary.cable,direct puh,etc.) �`
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing Deer 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)�� Method of test:
Air Lift Permit Program,1611 MSC,Ralergh.lvC 27699 1611
13b.Disinfection type:
Chloe. Tabs Amount: � ��2 LbS
Revised 6-6-701 II
1 Noah Carolina Department of Em iroamcnial Quality-Division of Water Rcso tees
Form GW
I