GW1-2022-03931_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For internal use Qnty:
1.Well Contractor Information:
Alfred Kiesling Sr
Ohl TO DE�C.RtPTtO� 1
Well Contractor Name ft. ft. QIv�
2670-A IL
NC%Veil Contractor Certification Number sT:: `FEIi �c tmg `
B & K Well Drilling Inc FROM TO DL-METER THICS rim MATERIAL 0 ft- I grs ft- 61/4 7n. SDR-21 PVC
Company Name 26�) 19£Ri }SFIZF �BS1Y 2c>. •:.:::.:'.
� r� l'O DiA�16rER TitICKN� MAIYRIAL
2.Well Construction Permit n: � FROM y� Ct ft, r°
Lisr all applicable well construction pennits r.e.t11C.Cotairv.Suite.Fanance.etc.)
ft. I ft. 1°-
3.Well Use(check well use):
Water Supply Well: -Fizowtf To DIAMETER $LOT$IZE THICKNESS MATERIAL
❑Age culture! ❑MunicipaliPublic ft. ft 1O
❑Geothermal(HeatinsiCooling Supply) ,'aFtesudential Water Supply(Single] tt_ ft. m
r
real Wane_S u t (shared)
C es d n r Su
pply v Y
❑indusmal.ConuuercialIli Sit
❑Wells>100,000 GPD FRont To XXTI'Rlni E�SPLAC *rMETHUD&ANJO NT
❑Irrigation Nun-Water Supply Well: 0 2 20 fzBEIIi;011tt6 Pour
❑monitoring ❑R=ovcry
Injection R`ell: fz ft.
❑Aqutfer Recharge ❑Ground watorRe-mediation ..,, ..........;::..;..::: ;: ::::: :•
��y" h��G� ... }:i:::r<;;n:?:z;;;::;;:::i;:<i:'i:'::'fi:.::;::.:.:.:o-::•:;:..:;;:.:,.�..:
0Aquifer Storage and Recovery ❑Saliniry Barrier FROM TO ft_ MATERAL ttvir__.1ENr METHOD
CAquifer Test ❑Stortnw'ater Drainage
ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DES O�(oobr_ nays.soD/rotk er:ui srsa anti
CGeothermal(Hearin/Coolies Return)
��❑ PT
DOther(e..xplain under=21 Remarks) ,rr CJ t ft. ft. �r1 f"
4.Date WeU(s)CompietW_j__A =-Fell ID# � ft. fz 4
C rt. 0
5a.Wefl Location:_ J
ft.
M
t f 1
Facility/Chylitr Name Facility Tl) (if applicable;
ft. ft.
F`�.
LA -3
r d� ft. ft.
Physical Address,City,and Zip
^::i::•;p>;::';:i%.>;i'.::;iS;::i:5:?a:::':'::::::;�... ... ...-._...
County. Parcel Identification No.(PW) .l i '_;d l iv++
5b.Latitude and longitude in degrees/minotes/seconds or decimal degrees:
(if w,oll ticld,one lat'long is sufficient) 22.Certrfi on:
ti W 3 �(3l-
Si�^a* of Certified Well Co..., Date
6.Is(are)the wetl(s): !lPermanent or ❑Temporary -
Br signing this lbtm.!herei+t•rtatijr.rear tier.:r0(s)+ars(%yarn)<'autrutred in accordatre:=i:h
7.Is this a repair to an existing well: GYes or nNo I5.-1.vCaC 02C.0100 or l5.4'VCtC 02C.0200 WeR Corttmuctiott Standards and that a cop•
this is a repair.ill our knonr.well t onstna-Iimi information and axn/ai the nature q.1 the of this mcnrd has Ixrn prm idrd to the•.rtl o
11 rrrr.
repair tender#21 remarks section or on the back ofthis.form. 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.only 1 GW-1 is needed. Indicate TOTAL N-MBER of wells (add'See Ovee in Remarks Box).You may also attach additional page,ifnecessary.
drilled: 1 _ 24.SUBMMAL YNSTRUCTIONS
9.Total well depth below land surface: y (f) Submit this GW-1 within 30 days of well completion per the following:
For multiple nrlfs list all Jepilu'ijtHjferent(example-3,a1200 and 2@1001
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft-) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
!f+rarer level is above casing.tore"+
6 1/8 24b.For Injection Wells:Copy to DWR_Underground Injection Control(lt1C)
11.Borehole diameter: (�-) Program,1636 MSC,RaleigL NC 27699-1636
12.Well construction method:
Air Rotary24c.For Water Snppiy and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county encironrne W health department of the county where installed
FOR WATER SLTPLY WELLS ONLY: 24d.For Water Wells prodncina over 100,000 GPD:Copy to DW'R,CCPCUA
r Air Lift Permit Program,1611 MSC,Raleigh.N+C 27699-16I 1
13a.Yield Wpm) ti O Method of test.
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 Lb$
Form GW-I North Carolina Department of En,ironcntal Quality-Division of arcr Rcs I cs Revised
m ) 6-1.-301x
I