GW1-2022-03927_Well Construction - GW1_20220412 (2)

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WELL CONSTRUCTION RECORD((;W-1) For Internal use Only:
1.Well Contractor Information: aw
., ...
Alfred Kieslmg Sr _14.3 �>;: <: :.: :<::;.:.:::.>:::;;;::;.:;:::<
FROM nt TO DESC YTIO�
Well Contractor Name `O,0 rt. Q ft- n �� r-
2670-A `,W fL ft.
NC Well Contractor Certification Number ....-::.. .. :. .... .. ;.:'::.....;
:E9F1'hE1Zi`,�: �� ermv�rcased�aelts;Og' LtQER`
FROM TO D1AylETER THICKNESS MATERIAL
B & K Well Drilling Inc
p ft !Jb ft 61/4 ' i°• S2R-21 PVC
Company Name
2.Well Construction Permit#: txonr •rO 1 utA>+erER nLICKNEss MnrER1:+L
fits all applicable well corurmr(ion pennius .e.UIC.Cormrn+.State,ban.'anc('.etc.) ft. f6 in,
ft. ft. 1O-
3.Well Use(check well use):
Water Supply Well: FRONT I TO I DIAMETER ILOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑_?vlunicipal/Public ft. ft- in•
❑Geothermal(HeatinviC•ooli,(g Supply) 2<dential Water Supply(single)PPY ft- rL in
❑lndusTrial!Conunercial ❑Residential Water Supply(shared)
i;j...._ i�3'F?isi;�:»:�si>r"�i«":�:>1>��:�: ;:`.�::�:1>�<::>:: :`i<.:`>:i::i'>:�»i;;'::;::<:<;>??>::
&.tat
❑Irrigation ❑Wells> 100,000 GPD FROM TO KILTERM V%IP1 nCE_NMNT METHOD&-1+IOVNT
Nun-Water Supply Well: 0 fL 20 ft- Bentonite Pour
❑Monitoring- ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Grouudwater Remediation
iil�:&41�`81GfCdY�1§:#'4F�4:6f le<i::y;r;i;:':�<;':2:i:::•: :::i:;:;.'i:;:iii::,::;::.:cg;.<;.;;.;::�::�::
❑Aquifer Storage and Recovery ❑.Saliuiry Barrier FROM TO MATERIAL- F•MPIACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainaee ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer FRILTd39GLOC ai>scbaiienrtE31`secesaaix %::°7;;:::::
FROM TO DESCRIPTION(wlor-hzrdntss.soflly k srsv+'imetnl
❑Geothermal(Heating/Cooliag Return) ❑Other(explain under#21 Remark) © fc kv
,� ft D
4.Date Well(s)Completed: is Well ID# ft. ft. S' i-4 IF fhmw
IW
ft. ft
5a.Well Location:
M_ y
Facility/On m Nae /Facility ED.#(ifapplicable) fr. ft_ rye
ft. ft. n i?'"u
Physical Address,City.and Zip — 9 ft' ft
Couary Parcel Identilicarion No.(PIN)
��p. i>�•n^r..1 ^
5b.Latitude and longitude in deb nisi _F,'G!'_t,^ ''degrees/minutes/seconds or decimal degrees: i
(if well field,one lab'lono is sufcicnt) 22-Certifi a• n•N W
6.Ware)thewell(s): OPermanent or ❑Temporary .—at fCenitied Wei .o r utm ', Date
Br si�mn�this>onrr./herehr rerTrjr rirdt the t:rll(sl,cas(tvrrr)< nsrrurred in arrnrdance airh
7.Is this a repair to an existing well: GY-es or nNo 1 s.4:vcaC 01C.010n or 13-4 N-CAC 02C.0200 Hell Coattruction Standards and that a corn
I1'rhis is a repair.fill our known well ransina:tion infortnatinn and arp/air,the nature nl the of rms record has lien provided in rho i•.r•11 owner.
repair under t21 rema,*s section or on the back o(717is iarm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.on)v 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L�`�' (ft) Submit this GW-1 within 30 days of well completion per the following:
Far mulr(ple aids list till deptln'if(kfferent(innmple-3Ca)200 anti 3(d1100'1
10.Static water level below top of easing:40 ) 24a. For All Wells: Original form to Division of Water Resources (DNA'R),
!%rru(er Ir.rl it uhat r casing,we'+ (ft. Information Processing Unit,1617,MSC,Raleigh.NC 27699-1617
I
il.Borehole diameter 6 1�$ (in) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC127699-1636
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 enrironmental health department ofthe cotmry where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells procincing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1,!K _ Method of test:Air Lift Permit Program,1611 MSC,Raleigh.ivC 27699-1 61 1
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lb$
Form GW-f North Carolina Department of Em ironmental Quality-Division of Water Rcsowccc Revised(i 6-201 x