GW1-2022-05743_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD(GW-1) For internal use Only:
1.Well Contractor Information: l
I
Alfred Kiesling Sr
FROM TO DE�C'RTMON
Well Contractor Name ft. o0 ft. 7 0
2670-A 00 ft p ft. �r-Cs
NC Nell Contractor Certification Number L9EiFiTER Nf ercas"
B & K Well Drilling Inc FROM TO DIAMETER THICt��E55 lffATERL.I
0 ft. I ft- 61/4 in- SDR-21 PVC
Company Nome
2.Well Construction Permit 0: I elto+l 7'o UTA VIt rtR nrtCKnEss MATERI:IL i
LLrr all applicable well colrsrruction permits fi.e.LUC'.Comtrv.State.t%ariancc.etc.)
ft. i fc. 16.
i°-
3.Well Use(check well use):
Water Supply Well: FROM TO DIA.ET. uorS1ZE rHIC1<nESc MATERIAL
O. culture! OOMMu�unicipaUPublic
❑Geothermal(HeatillJC0Ol111g Supply) ,B'Rt:stdcntial Water Supply(single) ft. ft. 1n.
❑lndustrlaCon nfet OR at dcn tlal WaU: "uPPLY
S 11 2reL)
❑Irrigation ❑Wells> 100,000GPD FRU➢I TO MvTERi.AI E*SPLACEME\TMEIHOD&.�D(UU+7
0 20 ft- Bentonite Pour
Nun-Water Supply Well:
❑Monitoring ORca:ovcry
Injection WeU: iz fr.
ouudwater Remediation
❑AqutferRecharge OrC'r }9c:5'_41�tOtGR3w Es:PK( &E le,:::r:><:•«:r:
❑Aquifer Storage and Recovery OSaliniry Barrier FROM To MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage
OExperimental Technology ❑Subsidence Control rc
❑Geothermal(Closed Loop) OTracer FROM
FROAf TO DESCRIPrtON(color.Dardness So reek vze.K.I
❑Geothermal(Heatine(Cooling Return) ❑Other(explain under#21 Remark
4.Date Well(s)Completed -?Well ID#
rc. ft. fi 4
Sa.Well Location:
ft. ft.
'RY it J,t7 d�-. ft. fr-
Facilitylo"er Marne Facility ell#(if applicable;
e fr. ft.
ft. ft.
Physical Address.City
t7ouaty ?aaccl WntiEcation No.(PIN)
5b.Latitude and longitude iD degrees/minutes/seconds or decimal degrees:
(if~roll field,one IaL90 a is sufficicnt) 4rd ' n•Rtied Well C nca or Date
6.ls(are)the well(s): 'JPermanent or OTemporary a s�
.r signing tics Joint.I herein.-rerun rRot rift:rll,)rca�r�r oggs`+t{u�mac t (h
7.Is this a repair to an existing well: G'Yes or !).No ;5..:4CvC 02C.0701,or iS.;.'f'CrC ll2C.Mn Itch t csFrltszvSzSfhlld�df a id r�h ca�v
!/this Fs a repair.fill out know-well candnrat,•ae infonnatian and Prnlair.tit.'narurs-n,''rn� .10hic record has beer,preridrd ro rho xrll o�firer. 20 LL^
repair under#21 remarkr section or on the back ofthis form. 23.Site diagram or additional well details- U N O\�1
You may use the back of this page to provide additional well construc'i-q far•
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ;;'
construction.only 1 Gil t is receded. indicate TOTAL'vUMBER of welts (add'See ovee in Remarks Box).You may also1i aim( e�i `n'ecClycat}.
d;�alZ.j 5
drilled: / _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v w (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple nt,11s list all depths ijthffrrent(trample-3(atL700'and 2@j001 i .
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water!eve)below top of casing:40 (ft.) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
If(niter level is abo,-e casing.trrr +
11.Borehole diameter 6 1/8 (in.) 24b.For Injection Weffs:COPY
to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,'NC 2 7699-1636
12.Well construction method:Air Rotary 24c.For Rater Supply and Opeo-Loop Geothermal Return Wells:Cony to the
(i.e.auger,rotary.cable.direct push,etc.) county ent�ronmenral health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Rater We1Ls prodncinQ over 100.000 GPD:Copy to DN'R,CCPCUA
13a.Yield(gpm) O Method of test:
Air Lift Permit Program,1611 MSC.Ralclgh,N1-27699-161 1
13b.Disinfection type:CIIIOr. Tabs Amount: I2 LbS
E
Form GW-1 North Carolina Department of Ern iroamcntal Quality-Division of Water Rcsk uiccs Revised 6-6-201 t