GW1-2022-05744_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GA-1 For Lntemal Use-Only-:
1.wen Contractor information:
Alfred Kiesling Sr
i FRO?%l I TO I DE5"TMONI
Well Contractor Name ft. 1 fc.
2670-A
NC Well Coymactor Cenification Number -Wells
TER�__l THjcjL,.ESS I MATERIAL
FROMTQ B & K Well Drilling Inc 10fr L 61/4 'o- S..DR-2,1 ,PVC
f
Company Name nmrsrG.' itital
2.Well Construction Permit E; 3 3 FROM 10 1 DIANItl R THICKNE&q MATERIAL
in.
Ejrr all applicable well colarmcdoll Pelrfts'.e UIC C010"v.State.7%aric,cc.ex."
ft
3.Well Use(check well use):
p1�.,ETEFt _5LOTSIZE TWI(-.KNM' I MATERIAL 1
Water Supply Well: FROM I TO
GAgpicultural! O.Municipal/Public ft
CGeotherm'al(HeatinsyCooling Supply) 2<c7s-id-vitial wat;n-Supply(sin;e i ft- fL
CladustriaKonunercial DResidential Water Supply(shared)
........... ------
Cirrigation 0 Wells>100,000 GPD L FRO"' TO . ------=.&CE4E.-T METHOD
rL 20 ft- Isentonite lPour f
Nun-Water Supply Well:
ORccovcry
ONIonitorin,
T-j--tio-W.U. fL ft.
OAquifer Recharge OGroundwater Remediation
0 Aquifer Storage and Recovery OSaliifity Barrier FROM TO HATFRIA1. 04PUL METHOD
C-AcuiferTest CIStormwater DramaLe
oExperimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer
FRO51 I To TO DESCRIPTIONcurdness Is ErRin_4M eMl
CGeothermal(Heatikz(Cooling Return) 00ther(explain under=21 RemarlLs)
4.Date Well(s)Completed—_5/Z;w 7-2--well IDS -7
,) fL
Sa.Well Location: 5- 0 Jl
—
0o It. -7 ft
FaL:ility/O"er Nam Vy
ft.
Physical Address,CK and zip
...... ..........
t 7 7 as
County parcel ldentificwion No.(PLN,)
5b.Latitude and longitude in deg ees/minute-s/seconds or decimal degrees:
(ifm,cll field,om latlloo is%ufficicnt) 22.Certification: j
N W _;6A&I� Date
6.Ware)the well(s): OPermament or OTemperary
rho,rnr,tril!s)w s(,v r9,or r
C
ctrccar
7.Is this a repair to an existing well: CYes or !]No .Vr X.wor. U 12C.0200 RV c, Ist
_PT�!
and Wr"F.1.;
?I Chic rrrnr� <becr '0140d M thO�.rll OWTCT. 4—it
7
repair raider#21 re-marks sectors or on the back orzh7s.rom. 23-Site diagram or additional well details:
S.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additi- Aeorc,onstr2uctizonzinf.
(add'See Ovee in Remarks Box).You may also attach additionawa. Jf2p,;C4
construction,only I GW-1 is nccded. indicatc TOTAL NUNTBER ofv,,clls �,j —,'r
Intyir, �, aSOG
drilled. 24.SUBMITTAL INSTRUCTIONS 011111 1
9.Total wtH depth below land swface: .a r 5' Submit this GW-1 within 30 d2VS of well completion per the following:
Fov muldpir tivils list all dapflis if&fferwn,(trample-3,q_00'and 2@1001 24a. For All Wells: Origina i 5orm to Division of Water Resources (DIA'R).
10.Static water level below top of casing:40 —(ft') information Processing licit,1617 MSC.Raleigh.NC 27699-1617
If meter level is abow casing.use-+"
61/8 24b.For Injection Wells.Cony to DWR_Undenground 14*-6011 Control(rUC)
11.Borehole diameter. (in-) Proeram,1636 MSC,Raleigd>NC 27,699-1636
1
12.Well construction method:Air Rotary 24c.For Water Supply a Geothermal ReturnWell Copy tothe
(i.e.auger,rotary.cable.direct push,etc.) county emironmental health department of the cOUotY Wnemre installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producill.over 100.000 GPD:Copy to DWR,CCPCUA
i�
13a.Yield(gpm) Method of test-.Air Lift i P , i,Pto rem,1611 MSC-i i -V- c�0199-16H
Chlor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-i North Carolina Dqarmcnt of Er.61ronmcn-al Quak-,,-Divisicn al War-RL'OLimcs Revised 6-6-2019

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