GW1-2022-03925_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Cootractor Information:
Alfred Kiesling Sr .:............... .. : . .... :. ......:.,... ......:.
FROM TO DESCRWnON
Well Contractor Name
2670-A L 2 (�� v
NC Well Contractor Certification Number <, ..... ...'...... .:...> '..:
B & K Well Drilling inc FROM I TO DIAMETER THICKNES$ (v1ATERUL
p ft. I ft. 6114 '° SDR-21 PVC
Company Name ._. ..
//��!, ;:t&:31�1ERG ' <E#a�'LISEY�: 'eerl3eslDal' '
2.Well Construction Permit#• I d-T i 7 FROM 1.0 DIA.MrrER THICKNESS MATERIAL
Live all applicable well cons mfction permits x.UIC.Cowrrv.State.Pan.'oacc.etc.) it. I ft, in.
3.Well Use(check well use): ft fc. 1O
$t;diEHPI:- .. .. ..
Water Supply Well:
PII FROnt TO DIAMETER I SLOT$IZE TXtCKN£$S MATERIAL
❑Agricultura! ❑!Municipal/Public ft. fL i°•
❑Geothermal(HeatinuiCoolittg Supply) 24idential Water Supply(single) ft- rL In.
❑ludustriaKonmtercial ❑Residential Water Supply(shared)
❑irrigation ❑Wells>100,000 GPD FROM To MlTERLAL EAIPLACEM. LNT METHOD&.10IUUNT
Nun-Water Supply Well: 0 iL 20 ft- Bentonite Pour
❑'Monitoring ❑RcLovcry ft. fa
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL f,MPI_4CEMENT METHon
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑TracerrBRiL3NGL4Cs ariabeiiidLs3lseces�arr >:<%::::;7:';:;:"s::
❑Geotbermal(Heating/Coolinge Return) ❑Other(explain under#21 Remarius) FROM To DESCRIPTION(color.haranccs son( k gram size et I
4.Date Well(s)CompletWA —well ID#
Sa.Well Location: ft. fL '
r�
' JD2�0
Facility/Chv ter Maine act ray M7 Wapplicable,' ft. ft. D
1 . , 1
W mt.Ct fr. ft. ^/
e '
Physical Address,City.and Zip ft. ft- APR 2022
County Pateel Identification No.(PIN) `y ;tG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latrlono is sufficient) 22.Certifies• n•
N W ^
6.ls(are)thewell(s): InPermauent or ❑Temporary Sipature fCenitiedWellC nuactor Date
Brsi,ninS Phis loran.lharehr rertifj r/rtir nine,:rll(s/was 7,aa,
ruc•red in a<cordmu•e:with
7.Is this a repair to an existing well: GYes or n- No I5A NC4C 02C.0I0o or 15.4 NC4C 01C.0200 II'e/l Construction Standards and that a com
!/'rhis is a repair.ill ain knoea well<onstnrc•riae information and er»lMr,the norvre n_(thr of this mend has htrn pro-ided to rh,•rrll owner.
repair under#21 remarks section or on the back of tlds form.
23.Site diagram or additional well details:
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicate TOTAL N IUMBER of"clls (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL rNSTRUCTIONS
9.Total well depth below land surface:_S:� (ft•) Submit this GW-1 within 30 days of well completion per the following:
For multiple rants list rill depda if ,dffferem(n'ample.-3Cal.200 and 2@0007
10.Static water level betty to of casino•40 24a. For?ill Wells: Original form to Division of Water Resources (DW'R),
1 Static
a share casing,we"p'. a (ft) Information Processing Unit,1617!MSC•Raleigh•NC 27699-1617
11.Borehole diameter:6 1/8 {in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276 99-1636
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 emironmental health department of the county Where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Pr mlt Pr am,1611 MSC.Raleigh 27699-161 l
13b.Disinfection type: Cf1lor. Tabs Amount: 1 /2 LbS
I
Form GW-I Nonh Carolina Department of Ens iro°mcntal Quality-Division of Warcr Resources Revised 6-6-2019