GW1-2022-05751_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1} For lntemal Use Only":
1.Well Contractor Information:
i
Alfred Kiesling Sr
FRONT TO DEFCRTMO."
Well Contractor Name
2670-A o ft. (/ ft. ✓ G
NC14ell Contractor Certification Number ....::.:. ..�::
::ilawf3�`FER'E::'ILHN6� 9rID1�ca9ed�$elLt':E)gi�fttQEit' ;..
B gc K Well Drilling Inc FROM TO DULMETER THICr:tiE55 KATER11,1
0 ft. I�0 ft. 6114 1° SDR-21 PVC
Company Name _.......::: :�:.::
t&37VER'.C§S�li? '.:Of� f3&EX :.....ice:
2.Well Construction Permit a I.U,0 � rxonl To ulA>�ert x ,xICK M1E55 MATtiRI:AL
Live r.11 applicable well tonsmfction pemri4s,5.e.GIC.Corwty.Suite.far.'arce.etc.)
ft. : ft in.
f, i ft. in_
3.Well Use(check well use):
Water Supply Well: FROM TO IVIAMETE 1 SLOTSIZB THICKNESS ...MA ER1 AL l
pAgricultural 0-Municipal/Publicft. ft I 1°
❑Geothermal(HeatinsliCooliilg Supply) 2'Residauial Water Supply(single) ft. cc in.
Glndustna1.Con1nen al
OR 'urn nal Wa:r Supply
(s
hared))
>:1$iiLi1i -
❑Irrigation OWells> 100,000GPD FROM To K.kTERL_L E*spLnCE_NM"TMstaoD&.1+tau�rr
Nun-Water Supply Well: 0 rL 20 rt Bentonite Pour
Omonitorinr ORcaovcry rr. I ft.
Injection Well: ft. ft.
❑Aquifer Recharge ElGrouudwaterRemediation ; s:i '>:::;
�
>:1'9c:S.M`Bs(�3Y"$L:Patflx'
OAgtiifer Storage altd Recovery ❑Sahitity Barrier FROM TO 1vL-\TF.R1A1, EMPL4CENIENT METHOD
OAquifer Test ElStorm eater Draivace
OExperimental Technology ❑Subsidence Control rt tt.
OGeothermal(Closed Loop)
tT Zlx'Bitil;E iN6 HOC atcb atiaitosltttfs it eecesasc).
racer DE4CR
FROAf TION(color.Itardliessl rook et<m nze etu
TO
OGeothermal(Heatine(Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. L r,�
4.Date Well(s)Completed- r� Z Well ID# oft' ft, t( :U
7ft. �
%a.Well Location:
ft, l ft. r' SAE
t
fl,e_ck rS-L L ft ft. /�
Facility/Cwner Name Facility M,'(if applicable;
to I q
Physical Address,City.and Zip 10dK DAY->.S J ft. n
•� Y
v_1_ll Y47I.7V- 3
County Parcel Identification No.(P1N)
I � I
56.Latitude and longitude in de.-reesiminutes/seconds or decimal degrees:
(if well field,one latrlono i<surl`icicntl 22.Certific 'o
W d--2z
6.Is(are)the well(s): Permanent or OTemporarc
S • ure Ceni:ied 'ell Coneor Date
i;r siFninS rris lantr.i nerenr re!?F'%hat rpe :rfl(s/.vas(t rr)ronstrucred in arcordmu-e::rdi
7.Is this a repair to an existing well ❑Yes or JNo :i.4 NGC 02C.010r or i5.4 NC,1C 02C.0200 TTWI Cotcc u va Standards and that a eqn
n%this rrcnrl has hrrr proridrd m rh,•.+,rll or nrr. `g '}�`�•
LJ ?• ..
this is a repair.fl/our knoaa well cnnstnrc:ra:inforrnatinn and erPlaL-.the namrF '' rl; ^•+
repair raider t21 remarks swzion or on the back grthis.form. 11.
23.Site dia„ram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additiona+pygl)ctr�eti n info
construction_only 1 GW-1 is nccdcd. indicate TOTAL NUMBER of wclls (add'See<)vee in Remarks Box).You may also attach ad t
drilled: 24.SUBMITTAL INSTRUCTIONS 1nfGr i3iaijt^,Cl Pr-•r=;,-,;,,. Ur
I z
9.Total well depth below land surface:--C (fL) Submit this GW-1 withini 30 days of well completion per the lollowi�n
For muldpie,mils lisr all dept/ts ifthJferent(cromple-3(1:200'rrnd 2(a!i00')
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR).
(ft,) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
Ij,rAer level is abu,e easing.the"+
6 1/8 24b.For Injection Wells:Cony to DWR Underground lnjection Control(TUC)
11.Borehole diameter (in-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '1
Air Rotary 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cable.direct push,etc.) county environmental health department of the county ueltcrr uLstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-161 I
13a Yield(gpm) -- Method of test: G
13b.Disinfection type:Chlor. Tabs Amount. 1 1/2 Lbs
Form GW-1 North Carolina Department of Em;rocuricntal Quality-Division of Warcr Rc ourccs Revised t+-6-201 x