GW1-2022-05727_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) ! For lntemal lase Only:
1.Well Contractor Information:
Alfred Kiesling Sr
14C3T'Y3 g'ZOPIias>i::::>:z::.. i":::
FROM TO I P7T0� �
Wet!Contractor Narnt i ft. I '? �� fr. I 0r�/�S
2670-A 3 IL
DtFft. ,tr
NC Well Crmractor Certification Number y�> }r�E;�i5-1 i��itt#tEssedBellS':fJglzEtQER
B & K Well Drilling inca�l ; T� I DLtv1eTER I rxrcl��Ess MATERLAL
0 ft. I 5 ft- 61/4 in- SDR-21 IPVC
Company Name
I<7(z�i�?4ER G :E F1Sli Qi eili<rmil:'
C?D.C� O �'ROnt r0 DIA�1h-rER THICK\FSS I MaTERG1L !
2. Yell Construction Permit 1 in.
CLrr,r.71 applicable well Corti tnsGorr pc nniLi .t.GlC.Comm,Seofr.ya�fmrre.¢r<.j
fi. fL I
R. ft- I in.
3,Well Use(check well use):
Water Supply Well: 1 FROM 1 TO DIA'd ETER I SLOTSIZE THICKNESS MATERIAL
CI A,ricultural �❑liunicipalPublic I ft. ; fL I
OGeothe mal(HeatlntiCooling Supply) ;�rtcsEdaltial Watcr Supply(single] ft- tL
! t -Supply(Shared)
❑IndusEna]!Contnlerctal ❑RtslLt:nna.Wale_�u
❑Irrigation ❑Wells>100,000 GPD L.7RU51 1 TO i �1.aMAL I EMPLACEME'+7 METHUD&.i�[UUh7 i
Nun-Water Supply Well: O rL '20 fL IBentonite (Pour
❑monitoring 0Rccoc-cry tL ft. I j
m
Injection Well: tL I fr. ( I 1
�Grouudwate Remediatiou
❑Aquifier Recharge ..�:_::::..; >k}>
OAquifer Storage and Recovery ❑Seliniry Barrier FROM i, TO NUTERIAL T.MPLACEIttENT METH00
CAouifer Test t7Stormwater Drainace
i
OExperitllemal Technology ❑Surb sedence Control Z�iBRgL3NLOG'aiisclir
fL ft.
❑Geothermal(Closed Loop) adtiedc s�e ::?<:r::'s«;:><:::%;;«za;:;::;<;; ::
FR091 TO I D CRrP270N(cobr.bard sowrvclt Yr+m.-dm etel
❑Geotheral(HeatinJCooling Return) ❑Other(explain under#21 Remi LrL
) ,01
4.Date Well(s)Completed- 1 l LZ well ID# 1
I ft. ft. S QjZ H
Ct. I fL .�Y�� � VI
Sa.Well Location:
' % I fr-
FaciliTy•/Or�rerName FacilitvMFfifapylicable` 1 fL I fL
,� ft. ft. I
Physics!Address,City,and Zip ft. fL
?::?i"s :i«:::=<(":f>:'>Couary ?a.cl ldcntification No.(PIN)
Sb.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if-cil ticld,am tatllona is sufcicnt) P
22.Cer"fica'on: 2
ti W
cn:--Weil Conzaor Dare
6.ls(are)thewell(s): nFermanent or ❑Temporarc
C
�r s:gin r.�aar;ont:.i itPrei*:rPlrt'r`'rue;rhr+:rll(sl+,11s(wPJPJ<nnsrruered in arcrrdmrrP::irir
?.Is this a repair to an existing well GYes or !!No 5.< C.GTr7r cr;5 I NC,4C 0IC.0200 0`Fll Construction Standards and that a Ca7n
o[,hj been proridcd to rho r/l owner.
q'rhiv is a repair.ill our kno%T wolf ennstnrtrrr'a:infc�raiimn Cnd P,LT'Clr.!nP r,G J,-F fn?
rPenrd bcs n
repair unrder#2!remarks section or on the back o'rkic form.-•'`r`'
�_Site diagram or additional well de .: ",Air
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells hates the saute
You may use the back of this page to- t9i9e•a a,1 p'", ,i ctipn info
construction.only I GW-1 is nccdod. indicaic TOTAL NUMBER of wclls (add'See O.•ee iu Remarks Box),You may also attachadditioral pages IFnecessary.
drilled: 2 24.SUB�II't'TAL INSTRUC U
TIONS 4 9 2022
9.Total well depot below land surface: y (fQ Submit this GW-1 within 30;d2ys til l 4 e-iRdIw 'ft-*yd' i":
Fa•multiply ncl/s list rdl deprin if&fe'rent(crumple.- �V%'Qnt.0G
10.Static water level below top of easing:40 24a. For All Wells: Original form to Division of`Hater Resour= (Dµ'R).
(ft.) information Processing Unit,1617 MSC.Raleisl NC 27699-1617
Ij crater ler'ri is ubat'e casing.w'r"+
11.Borehole diameter.6 118 C)
(y,) 24b.For Injection Wells:Cony to DWR_Underground Injection Control(IU
Program.1636 MSC.Raleigis INC 27699-1636
12.Well construction method:
Air Rotary 24c.For Water Supply andOpen-Loop Geothet mal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county®N=ronmental health department ofthe cotmty ahem installed
FOR WATER SUPPLY WELLS ONLY: 12
1d.For Water Wells prlTducin6 over 100.000 GPD;Copy to DW`R,CCPCUA
nn �r Air Lift I Permit Pra rrm,1611 MSC.Ralctgh.--C 27699-I61 t
13a.Yield(gpm) d S/ Method of test:
Chlor. Tabs _ 1 1/2 Lbs I i
13b.Disinfection type: Amount.
4
Form GW-•i North Carolina Deparrmcnt of lira iron,Taal Quality-Division at µ'arcr AC30urCc< Re:is d 64-301 t