GW1-2022-03904_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD((;W-1) For internal use Only:
1.Well Contractor information: 7777777'
Alfred Kiesling Sr FROM DE5CRTMON,
Well Contractor Name ft.
1
2670-A "I ft-
ft. I
.0
NC Well Contractor Certification Number FRONT TO DIA.vIETER THICFNE55MATERIAL
&
B & K Well Drilling Inc 0 fr. ft- 1/4'
SDR-21 PVC 6
C
Company-Name -w-.-JNNEW'tA51NG:0Ft-
FROT..1 .1,0 TH
2.Well Construction Permit ft. in.
Livr all applicable%vII,:0IIsV`1Ir60)'Pe'-Fn'q LlfC (;0"'Ily-Sta t valw"". ft. in.
W.:
1.Well Use(check well use):
FROM T DIAMETER CLOT SIZE THICKN MATERIAL
Water Supply Well: ON4unicipal(Public ft. in.
OAgricultural in.
0-Cicothermal(T4eati"g1C00li'I9 Supply) esldcnlial Water Supply(single) ft. fL
01ndustrial/Conunercial DResidential Water Supply(Shared) :G-RlDU::-
FROM TO K.%TERIAL LNIPLA E. E-NTIOMOD&AUMOUNT
[3]rri.ation owells>100,OOOGPD 0 "- 20 fL Ben I tonite Pour
Non-Water Supple Well: ft.
ON1011itoring OR=o%-cry
Injection Well: ft.
...... ....
OGroundwater Reniediation ...................
; .:X 010
ap,
OAquif�r Recharge 4C.X-0. !9E EINI Mm. oq
RE oSalmiry Barrier FRONT TO rvI.ATERIAL
ElAquifer Storage and Recovery oStormwater Drainace ft. I
C.Aquifer Test ft. C.
[3EXperimentall TechnologyOSubsidence Control —lif.... -77777��
.lit�
GGoothermal(Closed Ldo*p) OTracerFROM TO DESC- (wlor.hardnesswilt k
(meatinalCooliag Return) 00ther(explain under#21 Remark)
ft.
4.Date Well(s)Completed:,?—Well rD#
ft. ft.
Sa.Well Location: ft. ,
Cr.
Faciiiry/Owner Name Faciii.tv M�(ifapplicabie) ft. ft.
ft.
1,:26 ss
Physical Address.City.and Zip
Parcel Wntificarion No.(PIN)
County s or decimal degrees-
515.Latitude and longitude in degrees/minutes/seconds Y2 certification-
(il'wcil field,one latilong is'utficic"t)
r
N
Sispnature Cerzi d Well .011tractol" Date
- -Br 4/
6.11s(are)the well(s): OPermanent or OTemporary 'h
t•rer'tiJi rear the�on Co,wu ctjon*Siandards and that a ctq�%-
15,4!VCACO2C.0701)orli.4,N7eC�,CO2C.n2onii-- C.,,"
7.Is this a repair to an existing well-. E:Yes or nNo of this rect,rd has b,-ell p)-owded to rho�.r/l owner.
11 rhisix a repair.fill out kno—well and P.rpiair-,the nature".f rhe
repair under#21 remarks section or on the back ofthisfiDm. 23.Site diagram or additional well details:
You may use the back of this pale to provide additional well construction info
9.For Geoprobe/DPT or-Closed-Loop Geothermal Welts having the same (add'See O-e iu Remarks Bo,.).You may also attach additional pages if necessary'.
construction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL—INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-I within 30 days of well completion per the following:
Fur multiple.cells list III/depitis.if(ifffe?.en,(el(unple-3(¢200'anel 2@q 001
24a. For -..0 A 'AleUs: Original form to Division of Water Resources (DWR),
10.Static water le%el below top of easing:40 (ft-) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
level is abot-e eosins.use- 24b.For I1RjSSq2R ELILs:copy to DWP-Underground und Injection Control(IUQ
_
6118 (in.) Program, MSC.Raleigh��NC 27699-1636
it.Borehole diameter: gram.
Air Rotary 24c.For Water Supply acil I i J boo)Geothermal Return Wells:Copy to the
12.Well construction method: --re intal led
county en,ironmental health department of the county where(i.e.aupe,,rotary.cable.direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: 24d.For Water.welts producing over 100.000 GPD:Copy to DWR,CCPCUA
Permit Programl.161 1 MSC,Ram gl'.(gp_) Method oftest:
13a.FOR
(gpm) /4( ' Air Lift
Amu - 1 1/2 Lbs
Chlor. Tabs unt.
13b.Disinfection type
Division of v,'at-Resources Revised"-2019
Form GW-1 North Carolina Department of Sn%ironnicnial Quality