GW1-2022-05752_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORDAGW-1
1.Well Contractor Information:
513"I_7
R 'm
Alfred Kiesling Sr
OM TO DE.SCRiPrIO\
Well Contractor Name �Ll ft. I fc.
2670-A 0 ft.
NC Nell Contractor Certification Number
B & K Well Drilling Inc FROM TO I D C.":
R TEHC RUL
o
ft. 6 1/4' SDR-21 PVC
Company Name
FROM 1,0 DIAMETER THICKNE&; MAILKIAL
2.Well Construction Permit#: c It ft.
List all applicable well colrMcdo,pen, e.
L,fC*.Coturrv.Starr.VaHancc.err.)
R. jfL I ft.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOTSIZE T14ICKN MATERIAL
OAgi I ft.
0-MunicipaYPublic ft.
oGeothermal(Heating/cooling supply) 2<dential Water Supply(single) ft. fL
zidenTial Water Supply(shared)
01ndustriaKominercial ORL
Cirrigation oWells> 100,000GPD FROM TU KxTERLILL VKMACE3�`r METHOD&.0101J.m
Nun-Water Supply Well: 0 fL 20 fL Benionite Pour
ONMonitoring CJRccovcry ft. I ft. I i
Injection R`ell: ft. ft.
Groutidwater Remediation
OAquifer Recharge O
ClAquifer Storage and Recovery OSaliiiiry Barrier FROM TO MAT I ERIAL PLAC [ENT METHOD
CAquifer Test oStormwater Drainage ft. I
ClExperimenEal Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(color.bard eSsdt k ermt--izee.)
CGeothermal(Heating(Cooliag Return) 00ther(e.Vlain under#21 Remarks) ft. S let
4.Date Well(s)Cowletm-:,jq [j.2 -W X9
ell rD# go R.
Sa-Well Location:
n,aA N 70fL
FacilityloivneT Nam M
Name Facility-tw-ni LLt4 Facility ,(irapplicable" ft.
ft.
/,S-2 cS, ll Uret.La, -LA 11 ft. ft.
Physical.Address,City.and Zip
county ?"cl Identification
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifw'cll field,one lat/long is sufficient) zZ.Cc to 'on:
N -We e4v
6.ls(are)thewell(s): nPermanent or OTemporary S;=atA ofCaniied well Com Date
rhcr rhe,:-Pll(s) C ine
P ,ivOY4
.;5.4 NCj.00k.0J0ror 15.,,kC,4CO2C.020n _ '11.
7.Is this a repair to an existing well; CYes or !lNo �If riji ri
ff this isa repair.fill nutkno"r we'll -`11677"lim'and explai,-.Me'an"Fil"r h" _1 recnrd has bect,17,ol-ided in:the v.ra of
repair render#21 remarks section or on the back qfrjiwfibm. 23.Site diagram or additional well details: J U N Qj 2022
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional we onstruction info
(add'See Ovee iu Remarkt,13o--).You may al-af ach a itio
construction.only I GW-1 is needed. Indicate TOTAL XLTMBER ofwcIls ,I In C� . ­Z-Ax.
drilled- 1 24.SUBMITTAL INSTRUCTIONS D-NQ1BOG
9.Total well depth below land surface: SM (f )
Submit this GW-1 within 30 days of well completion per the following:
For muldple arils lisr,di depila ifififferent(example-3,�.200'anef 2@1001
24a. For All Wells: Original form to Division of Water Resources (DA'R).
10.Static water level below top of casing:40 (ft-) Information Processing Unit,1617 MSC,Raleigh.NC 27699-1617
jfivtjfer Intl isabatvcasing.use 24b.For Iniection wells-.Copy to DWR_Underground Injection Control(IUQ
11.Borehole diameter:6 1/8 (in.) Program,1636 MSC,Raleigh.,NC 276 99-1 63 6
12.Well construction method:Air Rotary
124c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
-talled
al healt
h
of
(i.e.auger,rotary.cable.dirrect push,etc.) county en department .county wh in,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to D%A'R,CCPCUA
Air Lift Pcrmit Pro.-n-arn.1611 MSC.Raleigh-N:7 27699-1611
13a.Yield(gpm) Method of test.•
13b.Disinfection type: Chlor. Tabs .kniount. 1 1/2 Lbs
RcvisLd"-2019
Form GW-1 North Carolina Deliartracrit ofEni ironinenral Quality-Division of Warcr RcsoLn:cs