GW1-2022-05745_Well Construction - GW1_20220609

CO1�iSTRUCTION RECORD (GW-11 For Internal Use Only`
1.Well Cootractor Information:
Alfred Kleslmg Sr
>`,l�t� ::..:.:....:.
FROM TO DSSC'RiP7T0\
welI Contractor Name 7 ft. ft- it, Q
2670-A ft o ft.
NC Well Contractor Certification Number
B & K Well Drilling Inc FROM TO DLLnETER THIM.'t_8 MATERUL
0 ft. I V1 7ft- F) 1/4 SDR-21 PVC
Company Name ///��� FROM IATE';:..
�J/ /�� X tltOAi 'I'O UlA\1E rl:R THICKtiE55 ATATERf:1l'.
2.Well Construction Permit#: �G` (((/// ft. i ft in.
Lis,-all applicable well construrdon penrirs 6.e.UIC.Co+arn.;.State.Vo'.anct'.etc.)
ft.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE TNICK�E$$ M.ATER1Al
OAgticultun! 0�Muunicipal/Public ft. ft in
OGeothettnal(HeatingiCooling Supply) 184idential Water Supply(single] ft- fL ra
Glndustn'aCon tnt -� t
ORCS de tl al Water Su
pply
1y
(Shared)hat t)
l8iit"ili
EN ACEy11:T(TMETHUD&AytUtl^T
Olrrigation ❑Wells> 100,000GPD FROM TO M�IERIAL SPL
Nun-Water Supply Well: 0 rt 20 ft Bentonite JPour
OMonitoring ORccovcy ft. ft.
Injection Well: ft. ft.
OAqulfer Recharge OCiroundwater Remediation
OAgtnfer Storage and Recovery OSaliniry Barrier FROM ro AIATF:RIAI. F.MPI_ACEMFM METN00
CAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control ft ft
OGeothelmal(Closed Loop) OTracer
;20:>BlE�7�;�0�'
FROM TO DESCRIPTION Toobr.eardn rack cram_ft,era)
CGeothermal(Heating(Cooling Return) OOther(e:(plain under=21 Remarks) fc• ft.
'I A R. ft.
4.Date Well(s)Completed. � ZWell ID# t
{(, ft
Sa.Well Location:
Facility MD (if1>Fz licable) ft.
ft
Facility/Oetamer Namgot.
/e o t) " ft. fL
ft
Physical Address.City.and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if-ell field,one latlong is sufcicnt) 22-Certifica on:
` W
6.is(are)the well(s): OPermanent or OTemperar}'
S. ura Cenitied Weil Co uactor Date
Zr signing riris form./herpi!+.-crrrifjv mar rite.:rll(s)+ens(tcerpJ onsrrvrred in areprdmx-p::frh
9.;.�G C n2C.4rOr o,is.; .nznn recut eaa 1 PlB+ i z
7.Is this a repair.to an e:istiag well: GYes or JNo l��r� _
!)This is a+rpai,fill our know well t-onsinttrtion nfonrarinn and erplair.the naturr of bc, ?f this.record has lxrnprat-6drd m!rhr rr/l oanrr. Z a = 'iy�
repair rntder#21 remarks section or on the back of this form. 23-Site diagram or additional well details: ''AA'' {�
You may use the back of this'page to orovide additio,ILAtlll�44ic232-2tfo
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction.only 1 GW 1 i;needed. Indicate TOTAL I�ZTMBER of wells (add'See Over'Over'iu Remarks Bo ).You may also attach additional pages if necessary.
Infof�,34j0n Pmc>;x.„;.^.g Ur:;!
dolled: 24.SUBMITTAL INSTRUCTIONS ^V'vQ;i CD i
9.Total well depth below land surface: fft) Submit this GW-1 within 30 days of well completion per the following:
fur multiple urlis fist 111f depths iirtafjerenr(trample-3(a'_00'aeA 2@ti 00'1
10.Static water level ochry top of casing:40 24a. For All Wells: Orignal foam to Division of Water Resources (DWR).
(ft-) Information Processing Cunt,1617 MSC.Raleicb.NC 27699-1617
if purer level is abat-e casi"A.are"+"
6 1�$ 24b.For Injection Wells:Copy to DWR_Underground Injection Control(LUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Rotary 24c.For Water Snpply and Olen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county environmental health department of the co-t taltere installed
FOR WATER SLTPLY WELLS ONLY: 2Id For Water Wens producing over 100.000 GPD:Copy to DWR,CCPCL'A
Air Lift PennrtPro_tam,1611 MSC,Ralwgh.lvC 27699 t611
13a.Yield(gpm) 1 Method of test:Air
13b.Disinfecdon type:Chlor. Tabs A .(mount: 1 I/2 LUS
I
Form GW-1 North Carolina Department of bn%iroamental Quality-Division of H'arer Rcs—cs Revised(rl+-2019