GW1-2022-05640_Well Construction - GW1_20220610

«i rONSTRUCTION RECORD (GW-1} For Internal Use only:
1.Well Contractor Information:
Alfred Kiesling Sr 'offaw
FROM TO DE.�C'RTPT70� /V
Well Contactor Name
2670-A
NC Well Contractor Certification Number { TEgS'
B & K Well Drilling Inc FROM TO D1AYIETER THICI:tiE55 rvUTERL4t
0 ft. I�y ft- 61/4 SDR-21 PVC
Company Name
>::f:
ERl:\L
2.Well Construction Permit F:�Wa 0(, 1 i FxoDI l rO utA�terER ntlCKnti55 Dtar
List all applicable well construction permits r.e.1UC.Corarty.Suite.i'ar.'ai,cc'.etc.)
ft. i fL in.
ft- i ft. in.
3.Well Use(check well use):
,... :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑. cultural 0-Municipal/public
it. I fL I is
CGeothermal(HeatinsiCooling Supply) 2'Rcstdential Water Supply(single] ft- ft in.
F11•i'€:>;>i<;:<:;;i::i:`tzi<>>i:<::ii:iS ::.<`»::<;>.;»' 'Clndusvtal/Conutterct t CRes1dennal Wan Supply(Shared)
z:t�s:L3t
Clrriga[ion ❑We]ls> 100,000GPD FRo l To nc�TERTAT EDIPLACE N7ME[HUD&.iDtUUM
Nun-Water Supply Well: 0 fL 20 fL Bentonite jPour
CMonitoring C]Rccovcry ft. ft.
Injection Well: ft.
t ft.
o GCireuudwater Remadiation ......: .....:::.;::�;.
CAqu[fer Recharge
>;�I�t:S.AcY$lGR3Y�L�4�15•c:l>f Ip}�i;r:&::<�::?;:.k^:Z;':2'..i#:i.;:?c<'ii;S;::;:':::;:•�;;:::<=:o:::.:
CAquifer Storage and Recovery CSalinity Barrier FROM TO MATERIAL F,MPt-,%,—IEKT METHOD
❑Aquifer Test OStormwater Drainage ft. R-
OExperimental Technology CSubsidence Control tL ft.
❑Geothermal(Closed Loop) ❑Tracer
i 'B3eiLtiiN6 L4 attach adUtierio� :i1 setesysi+3
FROM TO DFSCRrPTiON(cabr hardnes& rock ermt me.etel
OGeothermal(Heatine(Cooliag Retum) ❑Other(explain under#21 Remarks) ft. ft. 7 p
4.Date Well(s)Completed- •�'� 2-2'We11ID# I ft. ft. ` D r
R. u fL
Sa-Well Location: if',57
ft. ft470
. '
Facility/Ots+nt�er Name a J_ M It
Mz'(if applicable; ft- fL
4 f�a R,J to l 1 ft. i ft.
ft. fL
Physical.Address.City.and Zip
L Told
C K n
('ouniy Pamcl Idcntificarioo No.(PW1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
(if M•ell field,one latlong is sufficicnt) 22.Certification: C
w &
Date
6.Islam)the well(s): �PeTmanent or ❑Temporary
Si�ature fCeniicd well Coneor
Zr signing,ics Ibisr..1 hereht•cen rifp,nor me.:rll!sl 1.os(time)constructed in accordance:>irh
7.Is this a repair to an e:istiag well• pYes or JNo %5.a:�C.0 O2C.OIOl;or Is.:h`CiC 02C.n2an Tiell Casiruen''on standards and that a cm
Il this is a repair.fill our krio�a well<•anslnrcrirni infa tradnn cnd prn!ar.-.rho narurF n1 rno of rnis record has bren provided in rho nrll or .mer.
repair raider T2(rema%Fs secton or on the back o(this farm. 23.Site diagram or additional well details:
You may use the back of this'pav to provide additional well construction info
S.For Geopro I G or Closed-Loop Geothermal Wells having the same (add'See Ogee in Remarks Box).You may also attach additional pages if necessary.
construction-on
ly W-1 is nccdcd. Indicant TOTAL?�`UMBER ofv.�clls
drilled: [ 24.SUBMITTAL iNSTRUCTIONS
9.Total well depth below land surface: <Q 0 .5 (ft-) Submit this GW-1 within 30 days of well completion per the following:
fur'multiple nr((s list rd(Jeptln'ijrkjfrrent(rramp(e-i(els 00 «ro(J(d!1001 .
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR).
A) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
Il'rater level is abare casing.use'•+
lt.Borehole diameter 6 1/8 (in.) 24b.For Injection Wells:Cdny to DWR Underground Injection Control(IUQ
t�
Pros am.1636 MSC.Raleigh,NC 27699-1636
12.Well construction method:
Air Rota 24c.For Water Supply and Open-Loop Geothermal Return Weals:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county enN�ronmenral health department of the county Where ultalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodocina over 100.000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Prom,1611MSC.Raleigh•4C27699-1611
13a.Yield(gpm) 15 Method of test: (.,
13b.Disinfection type:Chlor. Tabs Amount. 1 1/2 LbS
f
Form GW-1 North Carolina DLpantncnt of Em ironarcnral Quality-Division of Warcr Rosoumcs RcrisLd 6-6-2019