GW1-2022-03939_Well Construction - GW1_20220412

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WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling S
FROM To DESCRTMOV '
Well Contractor Name ft. tt. 0
2670-A fL ft. L G
NC Well Contractor Certification Number : : •
B & K Well Drilling Inc FROM TO DIA-METER THICKNESS MATERLA&
Company game
p ft. I � ft. 6 1/4 in- SDR-21 PVC
. ..... .:::.;
:....:.....
2.Well Construction Permit tl �yy !l _ (_ FROMr0 DIAMEfER THICKNESS MATERIAL
Lnv,all applicable well construction pertnits .e.UIC.Coturrv.State,Variancc.erc.) rt. f6 in.
3.Well Use(check well use): ft- ft. iv
Water Supply Well:
1I::SCitEEhF
F}tOM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agriculture! ❑Municipal/Public ft. ft. in.
❑Geothermal(HearinziCooling Supply) l<dential Water'Supply(Single) ft. rL in•
❑IndustriaKonuttercial ❑Residential Water Supply(shared)
8.t,�ItOII't' ;.
Olrrigation ❑Wells>100,000GPD FROM TO MATERIAL E*IPLACENIENTMETHOD&AINIOUNT
Nun-Water Supply Well: 0 it 20 ft- Bentonite Pour
❑Monitoring ❑Rr covcy rr- ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑(iroundwater Remediation
OAquifer Storage and Recovery ❑Saliniry Barrier FRORI I TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormw'ater Draituage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑TracerBRi)FiEiTG ';t 'aitieris7i .i£:geeessia
OGeotbermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION'(color.b2rdness,so k zyp&er In size.etc)
ft. � ft.
4.Date Well(s)Completed:V Well ID# ft' �(( ft' / r!J fill ,S'i5/V
ft. d1 1
Sa-Well Location: fL r-
ft. ft. r/1
Faa/ility/OwrerName Facility it). 61'applicable; ft. fL
Physical Address,City.and Zip
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Si�REl!#AR7GS:<::::::ii:i7<i:'>:a.:;;::<:::>;:,:>:><? ':a>?f::Si'"%s: .>`:�:;i>:'.>5:"`'�.
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County Parcel Identification No.(PW)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,om]at/long k sufficicnt) 22.Certific on:
6.Is(are)the well(s): nPermanent or ❑Temporary Signature f Certined well C nsactor Dare UU
Br signing this rm.I hereby cer ro:that rite ivell(si teas(tvrre)constructed in accordance:vith
7.Is this a repair to an existing well: ❑Yes or nNo tAa NCAC 02Cfo.070r or I5.4 XCAC 02C.r2on Well Cotamvcdon standards and that a core
I)this is a repair.fill out known.well cnnsinaninn infonnatiatt and atplai:the naturr of the of this reenrd has been provided m the rr11 owner.
repair trader#21 remar kr section or on the back orilds 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: r,0 6 r (R) Submit this GW-1 within 30 days of well completion per the following:
For multiple melts list all depiln if different(tanmple.-3(ar2DO'anct.,@1001
10.Static water level below to of easing-40 24a. For All Wells: Original form to Division of Water Resources (DWR),
p =' (ft.)rtvter•level is uhut-e casing.use"+ Information Processing Unit,161TMSC.Raleigh.NC 27699-1617
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11.Borehole diameter•_6 1/8 (�) 24b.For Injection Wells:Copy to DWR Underground Injection Control(TUC)
Program,1636 MSC,Raleigh.NC 27699-1636
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 of the county inhere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DN'R,CCPCUA
13a Yield(gpm) —2 Method of test:
Air Lift Permit Program,1611 MSC,Raleigh.NC 2 7699-1 6 1 I
13b.Disinfection type: ChIOr. Tabs Amount: I2 LbS
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Form GW-1 North Carolina Department of Environmcntal Quality-Division of Warcr Rccourccc Revised 6-6-101 R