GW1-2022-05644_Well Construction - GW1_20220610

WELL C07NSTRUCTION RECORD (GW-1 For Interrial Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr 7777777=..'
........
i FROG( TO i
Well Courracra,Name
2670-A
_24
NC Well Contractor Certification Number X
VIFTER I T KIM I MATERIAL
B & K Well DdIling Inc 10 ft- 61/4 in- !SDR-21 !PVC
7�=777777-7.
Company Name
2.Well Construction Permit.,: r—W82 FRom To DIAME I L- M AL
AI M
rt. ; ft
Liar r7l applicable re,rits fi.e._17C'.Coirxm State.Verfam1c.ex.) i
ft- ft.
to
..........
3.Well Use(check well use):
Water Supply Well: MATE
0 VIAMFTE
L
ft. ft- in.
O.A.gricultural O.Municipal1publi
CGeothermal(Hwaillgicooling Supply) 2<dvitial Watt-Supplv(single) ft- rL in.
I r
oiRtsidential Water Supply(share
01ndustriaKonimercial
OinigaEion ovvells> 100,000GPID FRUNI I To AXTEU&L i VNIPLAC&--u-M
l t
.N -Water Supply Well: 0 rL 12o ft- Bentonite !Pour1
Oklonitoring E]Rccovcry fr. ft.
Injection Well: ft. ft.
CAquifer Recharge !,Groundwater Rernediation
CAquifer Storage and Recovery- OSaliuiry BarrierFRo^.l I TO ?.j..%TERIAL EMPIACEMMM MMOD 1
I , I
C-AauiferTest E]Storm%kater Drainage ft. i ft_
I
oExperimernal Technolop- OSubsidence Control
oGeothermal(Closed Loop) ElTracer
FROM I TO DESCRIPTIVI(COM bud saVroel( avant lie.etei
CGeothermal(HeatingC=Lingg m) 00ther(e.Vlain under#21 Remarks) i ft. ft. l --'V
4.Date Well(s)CompletW:i � Well MI.! L
rt. j IL
Sa.Well Location: (0.
(Qth 16_&Lgg X qe V� fA 4(1 ipgj�w Ij
FacilityiO"erVarn, Facil;tv M (ifatip[;cable, ft-
M.- K-4-f
ft.
_,je
fL Physical Address,City.and Zip JUN 1 0 2022
/407 1 !7— . Unji
County Pzrccl Identifica:iA No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if—cil field,one lattlong is Oficicnt) 71-Certifica'on:
N W Ta�T—
gy Date
6.ls(are)the well(s): nPermanent or 0-Temporary WEI C0r_=2c­oz
7hc, onsiruc,ee j*n,,,-,-rrdan,-e with
gnmg. 'dl Constru io S d a cojiry
7.Is this a repair to an eLLs4ing well: —Yes or !]N o ­,,NCAC`02C.02017 T, cr n landards an that
�frhis I.,a i-epair.fill our kno�r m.aiiM;ard P.rn'a,;:-.,h& ..'err.�cnrd havbcer provided to rho�.rll ow�cr.
repair wider#21 r�_ a,*s section or on the back ofrhu.fme,. 23.Site diagram or additional well details:
you may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction.-only I GW-I is nccdod. indicate TCTALIN�UIVIBER ofwcIls (.6d,Stle 0,-ee in Remark.,Bo:").You mayalso attach additional Pages ifnece&%ary.
drilled- 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For mufripir arils list all depiky iftiiffirren,(eromple-3tS!_7 00'and 2@!i 001
10.Static water level below top of casing:40 24a. For -U Wells: Orizinal form to Division of Water Resources (DWR).
Iform—ation Processing UniL 11617 MSC.Rpleich.NC 27699-1617
ffmiter fewl is aba-.-e casina.rose 24b.For Injection Wells:Cony to DW_R_Underground Injection Control(rUQ
11.Borehole diameter:61/8 (in.) Progracr�1636 MSC,Raleigh,NC 27699-1636
12.Well construction method;Air Rotary 24c.For Water Supply and:Open-Loop Geothermal Return Wells:Copy to th:.
(i.e.auger,rotary.cable.direct push.etc.) coutny environmental health department of the county wheire mztalled
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts gDro&cin-overloo.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /1y Method of test:Air Lift Permit P7xi,_,r?_rn,1611 MSC.I Raleigh.'YC 2769.�-Im I
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs—
Form GW-I Norih Carolina Department of En,roanrcn-LaiQuahry-D!,ision or wat—Kcsourccs Rcvisd 6-6-20 19