GW1-2022-05643_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD AGW-1} For lntemal Use Only:
1.Well Contractor Information:
l
Alfred Kiesling Sr �¢
FROM TO DESCRiPTlON
We]!Conrmetor Name ft. ft. -.4
14
2670-A i 4V 5 rt. slild it-
NC Well Contractor Certification Number L�t'ASIN6� t3r.:m'�i�9ed'sells g'ift-REit
B & K Well Drilling Inc FROM TO DIAMETER THtCICNESS Mi ATERLAL
Q ft. 1 6 1/4 SDR-21 PVC
Company Name }(c4TVER'.GSII '.tUSSE�F: PeEberiitai '
�W Wa�- d d 9 t FROM 1 1'0 D,AV7ErhR THICKNESS MATERIAL
2.Well Construction Permit#: ft. I ft tn.
List all applicable etll c0t+struC60"perciti e.LtJC.Cororrv.Stare. ancc'.etc.)
ft. i ft. to I
3.Well Use(check well use): I
I Z:St3tEEPt
Water SuppiV Well: FROM TO DIAMETER SLOTSIZE THICKhE55 MATERIAL
OAgricultura! ❑o�M�uunicipaUPublic ft. i ft
in.
❑Geothermal(Heatingicooling Supply) ,Bftts!dential Water Supply(Single) ft- fL in•
'(shared)
dC nal War:.:Su 1
' / ❑R es1 n Supply•' 1a :; >:;>?`:c;::;.:::;»<>::;::>:'ss::>: ..
GlndusYr,aL Conmtercrai i8:>uR
❑Irrigation 0 Weiis>100,000 GPD FROM To x�rERL�2 EUpLACE�*7 M. .. OD&:LIIUUM
Non-Water Supply Well:
Q ft 20 fL Bentonite IFiour
❑Monitoring ❑Ruovcry fr. fr
Injection Well: ft tt.
(' dwater Remediation
❑AqulferRechazge ❑ sroun
❑Aquifer Storage and Recovery oSalinity Barrier FROM TO
MATERIAL. F,M PIACEGlEIYr METHOD
CAquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control rt ft.
❑Geothermal(Closed Loop) ❑Tracer
Z <BRLtii3�6 iUG:attach ads ieded )#secesaan :.
FROM TO DESCRIPTION(ooior baroness,wntrxk':..•.2rmt nze.eto)
CGeothermal(Heatine(Cooling Retum) (❑Other(explain under=21 Remarks) ft• ft. fy d (119
�{ v1
l L__ l�
4.Date Well(s)Completed, j 6 Z2-1I ell ID#
Sa.Well Location:
5 Ct. ft.
� �� �� ,/ ft. ft. �
Fi--Ageg ,�.! f jz"5 1 r t rr. fL
Facility/OnTerName FacilitvTM(ifapplicable) _ ss
4 G a j� 661',dr ft. j ft z a
— ft. h.
Physical Address.City.and Zip
L . �L_ i!oyy1 /Z
County• ?axed Identification No.(PIN)
• r.�ar
5b.Latitude and longitude in dee ees/minutes/seconds or decimal degrees:
(ifw'cll field,one IatRong is sufficient) 22-Certifica' n: P
Siure fCenined Weil C c or Dare
6.Is(are)thewell(s): TPermanent or OTemporary G
t'r r�rinS tiis Jong.i herehr cm7tf,�lira,rhP�:rll(sl s(1vPlPf COnSIntClPd in areardm+CP::irtr
7.is this a repair to an ertisting well: ❑Yes or !]No ::.,�C..0 O'C.0l0r or 1.5.,ACIC 01C.nzOn ell Cotcrtrvctiwr Standards and that a ctm-
I)rhis is a tvpair.fill out knowr.well<nnrinrctiar infnnrarinu and ernlaL-.rite nature nfrhP
aftnis reenrd hGs!x•cr,prerided tn'rhr v'.rll ov ner.
repair under t11 remar kr section or on the back of?hic 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 wclls (add'See Ovee in Remarks Bo ).You may also attach additional pages if necessary.
drilled: 24.SUBMMAL r STRUCTiO-S
9.Total well depth below land surface: C _A3_ (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple mils list tdl depdu'if different(trample-3(4+_00'and?(d!iM
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft.) information Processing Unit,l l7 MSC.Raleigh.NC 27699-1617
!(nvter level is abor•e casir,,.use"+
6 ��$ 24b.For Injection Wells:Cony to DWR.Underground Injection Control(i11C1
11.Borehole diameter: p (in.) Program.1636 MSC,Raleigh,NC 27699-1 63 6
12.Well construction method:Air Rotary 24c.For Water Supply and O up pen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producvnlg over 100.000 GPD_:Copy to DW-R,CCPCUA
Air Lift PermitPro_ram,1611 MSC,Ralcigh,NC 27699-1611
13a.Yield(gent) Method of test:
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 LUs
Form GW-1 Nonh Carolina 1),panuicnt of En,irotuncnral Quality-Division of Warcr Resources Rcviscd 6-6-201x