GW1-2022-05661_Well Construction - GW1_20220608

For Lntenal Use only:
WELL CONSTRUCTION RECORD (GW-1) I
1.Well Contractor Information: I
I :
Alfred Kieslin 9 Sr ,4: : > : ::> ::>:::::>>:::::;::::::::>:: : :<<::>::>:::::: ::>::<:>>.: >::: >:: :::»>:::;;:::.:.
FROM I TO I Well Coutactor Name i C C) t. L1�.. IDE5KCRtP7�T0\ — ^
C � L0" /S
2670-A I < fL ft
'
NC Well Contractor Certification Number y' EgEggY 'L#acm cassed'tc�l)s3�$:i �F (i ��
B 8t K Well Drilling Inc TO I DL�nETER I Txtci`,>ss MArtRLar
i0 ft. 8b n- I6 1/4� in- SDR-21 !PVC
Company Name ia
:tftRG I SffD£ E-Rom TO
2.Well Construction Permit
•tl
fL T in• j
Lirr all applicable%,ell cotli rnirdon pNrrits;i.e.LrfC.Coratn%.State.t`armrCE.ezc.; .
ft- ft. i in.
3.Well Use(check well use): 777777777.
tZlSCt€€fF::; rc
Water Supply Well: FROM TO I DIAMETER I 6TSIZE ' TFi1CKPE5$ I tiATEKiAI i
0A,encultura! 0-muunicipaUPublic j ft. 1 fL I in.
❑Geothermal(Reatin_iCoolillg Supply) 24idvilial Watei Supply(S111RIC) ft- I ft. I rn i
i -Supply(shared)
Ware, u sL•.t e ttal �tstL n 0 R P rc 21 P ,
duscn..l Con tore r
! E"tPLACEME'\7MEIHUD&i,tUti"r7
01nigation ❑Wells>100,000GPD ' FRont TO TM.TERL&
Nun-Water Supply Well: 10 n 120 fL lBentonite Pour I
OMonitoring ❑Rccoccry
Injection Well: r fL ft.
CAqurfer Roe CGrouudwaterRemediation
Recharge
:;mac:S:Aa\'$iGR3y-$LP!�34�� le
F.MPLACEM1IFTT METHOO
CAquifer Storage and Recovery GSalittiry Barrier FROM I TO i MATE RIAt.
CAquifer Test ❑Stormwater Drainage fr. ft. j
OExperimerttai Technolop GSubsidence Control I £L fr.
❑Geotherma!(Closed Loop) OTacer
FROM I TO DESCRMTfOX(color.hardneR wVrock -
-rmr sic.erel
IDGeotberma!(Heating(Q=lin_Return) GOther(e..Vlain under#21 Remarks) I ft I O ft. 0 /v
I
3.Date Well(s)Completed- Well ID& i l® R. 0 ft• I �©tt/ S o/
ft. fL i dDl`
52.Well Location:
ft. I Q ft. i X p j
FacilitUUytoa ery ne Facility MF(,ifzzpp!icablet
Y`Y2
fL
Physical.Address. ity.and Zip ft '�• ... ... ..
WIN V
County
Pa!xl Identification No.(PLN)
`1 Pt�C
Sb.Latitude and longitude in degrees/minates/seconds or decimal degrees: Q«'
(ifw•c!i fiold,one iatllongg is sum'cicnt) 22.Certifita6 <
W S�y
6.is(are)the well(s): nPermaaent or -Temporarc
5e_.zun Oternied Well Con_zcwr Date
ard rrreig' -hat the•:rlifsl curs(srre)<onstr reed in atr
! we:v;ri;
�+ '�,,::\-G C rzC.OlOr or j--,,NC C 02C.0200 r.2;t Cor�taucSwt Standards and that a ctm'
7.Is this a repair to an existing well: ❑Yes or _No
1)'rhis is a repair.fill our knot+a well cnnstnrczirr.:njc rraunn crd rtpieir me
,(,-his.rr..r rd has brcr,provided to rile..rll ow.arr.
repair:nrder t21 remarks secdon or on the back orzh_z.1b, 2.3-Site diagram or additional tvell details:
S.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
consructior..only 1 GW-?is nccdt�. indica[c TOTAL NUMBER of wc11s (add see O`-ee ill Rem
arks Box).You ma also attach additional page,if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:f QS (ft.)
Far multiple imps list rdl depilu'ijtdfJ-rrenz(sample-3(�00 and 2(d!f001 Submit this GW-1 within 30 days of well completion per the following:
,1 24a. For .All Wells: Origaal form to Division of Water Resources (DWR).
10.Static water level below top of easing:40 (it•) Informaaor.processing Unit.1617 MSC.Raleigh NC 27699-1617
(j::Eder lnel is abate casing.mr"'` I
11.Borehole diameter.6 1/$ (;n,) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(TUC)
Prosram.1636 MSC,Raleig';NC 27699-1636
12.Well construction method:
Air Rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push.etc.) county ent ronmenad health department of the cotrnty ahem metalled
FOR WATER SUPPLY WELLS ONLY: j 24d.For Water Wells prDdncina over iOO.Odp GPD:Copy to DWR,CCPCLA
Air Lift j Permit Pro_rzm,16l1 .MZSL.Ralergh.:11-27699-IS1!
13a.Yield Om) Method of test: (., I j
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 Lb
i
Form Gw-i North Carolina D�panmcnt of Er.:roturl a a Quality-Di�isioa of\Varcz_K:ouzo: Retiwd"-201 R