GW1-2022-05746_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1} For lntemal Use Only:
1.Well Contractor Information: '
Alfred Kiesling Sr ,4.,.> ;:;:«:;:.:::;.::.:::;:,.;:..;;.::::<.;:.;:.::;.::.»::..:.>;:;:<>
FROM TO DESCRIPTION
Well Cotrtractor Name ft. Oft.
2670-A ft. �G^
t
NC Well Contractor Cerrification Number °.i_•+::EFtTE1Z:�`=>siA`6` Ititm' E::;:::::..:.�. >:.:�;;:>:.:::.casedaElls;U :�tQER
B & K Well Drilling Inc FROM TO DLALMETER THICKNESS MATERUL
0 ft. 9 ft. 61/4 i° SDR-21 PVC
Company Name
� J `2�'�1�R G;>tS1N?ly C#Q�'FISDFE': •rsDal: "'}
2.Well Construction Permit 0:3��'/ - V I 7 _ FROM TO DIAVIErER THICKNESS MATERIAL
Lirr all applicable well construction pennits fi.e.CrIC'.<.'orum<.'orum.Stn(e far:antr.etc.)
iR.
ft.
3.Well Use(check well use): ft- in-
Water SupplyWell: FROM Mf1E I #'
TO DIAMETER I SLOT SIZE TNIC KNE$S MATERIAL
❑Agricultura! ❑MunicipaUPublic ft. IL in.
❑Geothermal(HeatinJC'oolin;Supply) 2Rtstdential Water Supply(single) ft. fL in.
❑Inds settallContraercial ❑Residential Water Supply(shared)
lsrti313II 1
O Irrigation ❑Wells> 100,000 GPD FROM To MATERIAL ENIPLACE-NIUNT METHOD&.1-MOUNT
Nun-Water Supply Well: 0 ft- 20 ft- Bentonite Pour
❑Monitoring ❑Rccot-cry ft. ft.
Injection Well:
rt. ft.
❑Aquifer Recharge ❑Groundwater Rernediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Teat ❑Stortnwater Drainaee ft. ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ? >ERiLIS31TGiOC�atttaclsaFteiia3s4#seces+atx:::r sr::.::...;.>:.
❑Geotbermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DES IPTro'X(color.hardy —Trmic gram sera NCI
4.Date Well(s)Completed::'Y/7'IWel1ID# ft. f 0 ft
/5a.Well Location: Zvi VEI�
l l7 b Id l / ■d>rv><yJ Q ft. ft. i
Facility/O mer Name Facility M#(ifapplicable,, ft. ft.
2 1 -
Physical.Address.City.and Zip
T Oaf, 65
County N ccl Wntification No.(PW)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latilona is sufcicnt) 22 Ce - e on-
N W �- to 2,-
6.Is(are)the well(s): JPermanent or []Temporarygnat ofCenitied well Conuactor. Pak
Br signing riric>orm.!hereF?-rrr7ifj that tier r:rll(sl krs(werrJ<»nsrrue•red in nrcnrdauca:rirh
7.Is this a repair to an existing well: CYes or !nNo t s-.(:VCAC 01C.070n or]S.a ACAC 02C,0200 Mell Construction Standards and that a cram
nfthis record hac been r orided ro the+.rll ow nvr. `"'"" 1 "�
L)'rhis is a repair.fill our knoMn.well cnnslnrcainn infonnarinn and exnlair,the narvrr rat the P-
repair rider`;2t remarks secron or on the back ofrhis form. w ,.. # D
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hawing the same You may use the back of this page to provide addition a+ g(]c c o
construction.only 1 GW-!is nccdod. indicate TOTAL NTUMBER of wells (add'See Ovee in Remarks Box).You may also attach ad�j 91 p srtf .
drilled. I _ 24.SUBMITTAL INSTRUCTIONS
Infio;svic� ?r •L�•z:r:g Unp
t-,a,r
9.Toffi1 well depth below land surface: A✓� M) Submit this GW-1 within 30 days of well completion per tYe t°oilowin�g 7
Fur mulrple url/s lisp ait depih,-ifrhffer-en i(trample.-3(a�_00'ant_'(d!100�
24a. For Wells: Original form to Division of Water Resources (Dvt'R),
10.Static water level below top of casing:40 All(ft.) Information Processing Unit,1617 MSC,Raleigh.ATC 27699-1617
lJ nvter level is whore erasing.we"+"
11.Borehole diameter:6 1/8 {in.) 24b.For Injection Wells:Copy;to DWR_Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable-direct push,etc.) county entironmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1� Method of test:Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-161 t
13b.Disinfection type: Chlor, Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Deparlmcnt of En,iroamcmal Quality-Division of Watcr Rc ourcfcs Rcyiscd 6-6-2019
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