GW1-2022-03996_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-D For Intemal Use Only-
1.Well Contractor Informatiioon:
Alfred KI s mg Sr
Well Contractor FROM nTO DESCRIPTION
Contractor Name
2670-A UUa ft. i G �S
NC well Contractor Certification Number
15_V>I IE1t.-IVO ¢rm esye3 elis; ga£RER' :<.::::...•.?:«;::>'?:;>;'<;r>'!
B & K Well Drilling Inc FROM TO D1A_yIETER THICKNESS I MATERL•1L
ft 75
ft- 6 1/4; i° SDR-21 PVC
0
Company Name
2.Well Construction Permit#: t 7 / rxont To utA�terER THICKNESSMATERIAL
Ltrr all applicable well construction penniis fi.e.UIC Corurty.Store.i%ar."ante.etc.) ft. f6
in.
ft. ft. i°-
3.Well Use(check well use)--
Water Supply Well: FROM TO DIAMETER E
SLOT SIZE THICKNESS
..
SS MATERtAI
❑Agricultural ❑IvlunicipalfPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) BRratdential Water Supply(single) ft- fL in.
01ndustrial!Commercial ❑Residential Water Supply(shared)
O Irrigation ❑Wells> 100,000 GPD FROM I TO MATERIAL E,NIPLACEMENT METHOD&.1ntOUNT
Nutt-Water Supply Well: 0 f6 20 f` Bentonite Pour
❑monitoring ❑Rccovcry ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge O(iroundwater Remediation ::<:;i;:.;•::.:;:.......
::1�?fi.41\`9t�Y�I3:P.'aiF3f6f. .. ;;;;<>::;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.MPIACEMENT METHOD
O Aquifer Test ❑StormwaterDrainage ft. ft_
OExperimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer
❑Geothertal(Heming/Coolke Return) ❑Other(eeplain under#21 Remarks) FROfJ TO DESCRIPTION(mlon hardness so rock emir size.ere-!
ft. 0 ft. y
4.Date Well(s)Completed^ ZZ Well ID# 1t. 45- ft. r�Q J!
Sa-Well Location: ft. le'b fL
l ft, ft. Ir
/ onant�CL
Facility/OwmerName FacilirvM# ifapplicable) ft. fL
� ft. r.=1'�.th7 Q v� - .
r
Physics Address,City.and Zip v ft. ft. v r•'•'"
"
County Parcel Identification No.(P1N) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-cil field,one Iatilono is sufcicm) 22.Certification:
N R
6.Is(are)the well(s): IJPermanent or ❑Temporar} .mat ofCert.tied well Contractor Date v
Br signing this Jotm.I hrrel!t•rrrtijr tits!rite+:rll(sl+ s(urre)<�oastrucred:n aernrdanre:rich
7.Is this a repair to an existing well: CYes or "JNo t5.a:VCaC 02C.07011 or i5.4 A{AC 02C.n200 nett Corestr:cn!on Standards and that a enm
L(rhis is a repair.fill out kno�r,well ennstntt:rfnn infonMrinn and erPlair.the narurr n)'rhr (?(this reenrd has!eon pro)ided to the xrll owner.
repair!order t21 remarks section or on the back of this 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 NFUNIBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ') Submit this GW-1 within 30 days of well completion per the following:
Fur multiple nr[ts list all depils if thffrrenr(Trample-3(a2 00'anti 2(d!1001
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DIA'R),
(ft.)/(+rater leerl is uhure erasing.use Information Processing Unit,1617!MSC,Raleigb_ATC 27699-1617
"+"
11.Borehole diameter:6 1/8 (in) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
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 pushr etc.) county emironmenml health department of the county inhere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producink over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpnl) L'-6 Method of test:Aiilr Lift Permit Program,7611 MSC,Raleigh,NC 2 7699-1 6 1 I
13b.Disinfection type: CfilOr• Tabs Amount: 1 I/2 Lbs
1
I
Form Ctw-1 Nortb Carolina Depanmcm of Em'iroamental Quality-Division of Watcr Resources Rcviscd 6-6-201A