GW1-2022-03934_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alfred Kieslin Sr
9 FROM TO I DE.SCRTMON'
Well Courracror Name t 0
f Tt
2670-A L a fr. /if* v
NC Well Contractor Certification Number
pp ..-•�(i)F1'PF:R`�:�i:SLNG� ¢'r.:imvrt>�i�§rd�$e(ts:;�Hi�N. ..::.:; .. . ..
B K Well Drilling Inc FROM TO DIAMETER THICIC.NFSS MATERLAL
0 ff. Is ft. 61/4 in SDR-21 PVC
Company Name
p _ 79NN .R6 <'E>fkT1SFF etitliesioai("
2.Well Construction Permit# V � ��e_.t!_ FROM 1,0 DIAMerER THICKNESS MATERIAL
LLrr all applicable well consm ction pennies 5.e.U1C.Coturrv.State.1%seance'.etc) ft. fL in.
ft_ ft. in.
3.Well Use(check well use):
Water Supply Well: t�::SC3tFgrz
FROM TO DIAMETER SLOT SIZE THtCKNES,C MATERIAL
❑.Agricultura! ❑Municipal/Public ft. fL in.
❑Geothermal(HeatmJCooling Supply) 13<dential Water Supply(single) tt. fL in.
❑Industrial/Commercial ❑Residential Water Supply l (shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO EAIPLACENMNT METHOD&.infOUNT
Nutt-Water Supply Well: 0 iL 20 fL Bentonite Pouf
❑Monitoring- ❑Recovey ft. ft.
Injection Well:
ft. ft.
(]Aquifer Recharge ❑(iroundwater Remadiation :;:.:.::.:_.::.:.:.::::•..;::.:.::.:
V.::::.:: :k�< : :;r:::;:`;;:Y;`2:L:5: :<i::;i»::;:�';Y::
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F,MPI-ACEl%tEIYr METHOD
CAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer
DES. TPTtO�(color.hardness,sotUroek seam sizes ete.l
❑Cieotherrnal(HeatinJCooling Return) ❑Other(eeplain under#21 Remarks) FROM TO
Oft.
4.Date Well(s)Completed�l3 d 2Z We11ID# ft. Q ft. 11lGlj a/tvw o I
5a-Well Location: 3. F-D R. c5 fL iJ h
V �
t
Facility/Oc` erName FaciftvID (ifzpplicable; ft. fL
Physical Address.City.seed Zip ft, ft. r¢
rrt+L l ,.... ........
: .,... ................
Jr
Countv Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/Seconds or decimal degrees. _ u�p�,1
(ifu•ell field,one lat/lono k suffreient) 22.Certi ca' n: n tP�`,�y:Cj%�q 1 Ifi
N R'
6.ls(are)the well(s): OPermanent or ❑Temporary Sipature fCenified well Contractor: Date
Br signing this loon.I herehr rer•ti jr Thar nine+:el!!s/+gas(rcereJ rortstruned in accordmxe+rirh
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 1S.4 NCAC 02C.0200 A`ell Cotarmcriwn Standards and that a com
1)'rhis it a repair.fill our kn"r rvell<»nstnrctiwr infonnminn and arplair,the norurr of the n(this record has brren provided to the i•.r/l owner.
repair raider-T2l rema,kr section or on the back ofrhic 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-i is needed. Indicate TOTAL NUMBER of wells (add'See Ogee in Remarks Box).You may also attach additional pages if necessary.
domed' 1 _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: %2-P,r (R') Submit this GW-1 within 30 days of well completion per the following:
For mulriple nr/ls list all deprlu•if tkJ`rrenr(Trample-3(e�_00'and 2@100)
10.Static water level below to of casino•40 24a. For Pill Wells: Original form to Division of Water Resources (DWR).
!j miter level a<thu+r casing.eve"+"
p b. (ft.) Information Processing Unit,1617',MSC,Raleigh.ATC 27699-1617
11.Borehole diameter:6 1/8 24b.For Injection Wells:Copy to DWR.Underground Injection Control(TUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
11.Well construction method:Air Rotary i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county enrirrmmental health department of the county inhere installed
I'
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing:over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 D Method of test:Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-16 1 1
13b.Disinfection type: C.hlor. Tabs Amount: 1 1/2 Lbs
I
Form GW-f North Carolina Department of En,tronmontal Quality-Division of water Rc ources Revised 6-6-201 x