GW1-2022-03935_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr ,4
FROM TO DESCRiPTIO\
Well Contractor Name ,d
ft. ro ft.
2670-A
NC Well Contractor Certification Number
la: Est: etmvtca9etlsells:Ol);I�IQER'
B & K Well Drilling Inc FROM TO DI LMETER THICKNESS MATERUL
0 ft• I ! ft- 6 1/4 SDR-21 PVC
Company Name _ ... .....:::-;_.....::.....::':�:''::;!«
� + J �� � 2&:3t�3NERC§;ill�>(3I��FlB.t�: ees�erinaP:c[as¢d."� .
2.Well Construction Permit 9: FROM TO 1 DIAMErER I THICKNESS I MATERIAL
Cisr all applicable well construction permits 4.e.UIC.Coratrv.State.Varance.etc,/ ft. ft in.
3.Well Use(check well use):
Water Supply Well: FROM
FFtO�f TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultuta! 0-Municipal/Public R. ft in•
❑Geothermal(HeatingiCooling Supply) I<dential Water Supply(single) ft- fL in.
❑Indusrrial/Conimercial ❑Residential Water Supply l (shared)
>«it
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL LNIPLACErMNT METHOD&APIOUNT
Nun-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑Monitoring ❑Rccovcry ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`'1�.�5.9N�I�+R�3w�'L.1'4f'34.�if >: 1e}....... ::.;:::•:..:::::
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I r.MPI-A,CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer St#BRLtiiN1 OG sateiitil #eecessrr;E: >cz`>s:>;[:: >:;z»:i<'>
FROM TO DESCRIPTION(color.Eardness.so rock me.etc)
l7Cieothelmal(Heatine/Cooling,Return)
�, ❑Other(explain under#21 Remarks) ft "' £t O
4.Date Well(s)CompletW- ell TD# ft. � fr.
f
Sa.Well Location: O ft. O_ ft CE1p
n
WGt 1 �e
Faacncility/C6nermaame FacilitvlD (Ifapplicable) ft. ft
Physical Address,City.and Zip G«� �j ft. ft. ZO 7
p /Q C Zi:RED fR7i S: (^
Counn ?seed Identification No.(PIN)
5b.Latitude and longitude in degrees/minateslseconds or decimal degrees:
(if ucll field,one lat`long is sufficicnt) 22.Certification: 2
w � t� —6
6.ls(are)the well(s): (nPermanent or ❑Temporary Si_ature ofterti6ed Well Contractor Date
Br signin.o r thin Joan.1 herel t• errifr that me+:ell(s7+cgs(t re)rvnsrrucred in accordmuv with7.Is this a repair to an gusting well: GY'es or !]Not5.a MCA 0JC.0700 or I5.4 NCAC 02C.020n n'a7t C turruction Standards and that a com
lfrhis is a repair.ell out kno%r well ranctrucii n infnrtnatinn and explain,the natvry of rhr of this record has born provided to rhr•r.r/l oumer.
repair under#2/remarks section or on the back of chit 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 i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'iu Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L?A� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple urlts list all depdu'if ,dtffe•rear(maniple-i(a�_00 and 2@!1001
10.Static water level below to of casino•40 24a. For_All Wells: Original form to Division of Water Resources (DIA'R).
p ,'11+rater terel u•uhvre casing.eve Information Processing Unit,1617,MSC.Raleigh.NC 27699-1617
..+'.
11.Borehole diameter:6 118 (in) 24b.For Injection Wells:Copy to DWI-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC j27699-1636
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 enrironri l health department of the county udrere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:_Copy to DWR,CCPCUA
13a.Yield(gpnl) 1(l
/� Method of test:Air Lift Pcrm)tprogram,1611 MSC,Raleigh,NC 27699-16 1 1
{,,
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form G W-j North Carolina Department of En,irottmcntal Quality-Division of Water Resources Revised"-201 k