GW1-2022-07267_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD GW-1
For L*Itenal use only,
1.WeR Contractor Information:
Alfred Kiesling Sr
14::13:ii> _
well Contractor Name
FROM TO DESCRtP170� ..._.
2670-A
NC Well Cotmactor Certification Number ,.,/1 // ��B & K Well Drilling Inc FRom TO �..!
Company Uame ft. DIA>tETER THICti*iEss
D I sj~ ft 61/4 is SDR-21 PVC
xc�
2.1Ve11 Cottstrnction Permit t7tOM r0 D1A-14 'R TH7CKtitSS .
Girt a/1 applicahlr well cortsrnrrGa„ r r AtaTERIAL
LTC(.orurty.$7nte.
3.Well Use(check well use): O ►• 7 G
ft.
Water Supply Well:
O- f!t:D12UI31FKODI TO .....I DIAMETER $l0'r SIZE THICKNESS -MATERIAL
clMunicipaUPublic
❑Geothermal(Heatin_iCoolin Supply) _,� ft. R I in.
S PP Y) idRo'tdential Wattu•Supply(singlci
OJndustrial/COmmercial tt FL
is
ORt:sidcntial Wat;r Supply(shared) ...
❑Irri�'at(On �.ifLt3F!b:::;`.:i>;:;+:>`:2:�;<:>•"i;'.;ii:;:i;:?:fi>�:i.i��:;;:.::�>:i2?c;r<":-c].-:;i;:;.:::�:;;.::;.;:,::>:::�::.:;�::::.<;
❑Weris> IOO,OWGPD FROM To - aL�iERrtiL .. ;. .,.;.��PL7o'!?LrA
..::.:.::...:.:::;.:.:.:..-%I.o::.:..
Nun-Water Suppt}•Weli: •i�lUtMO1\Ronitoring 0 rt_ 2� fc BentOfllt2
OR zoccry
Injection RelL ft. ft_
OAgwfer Recharge OGroundwater Re-mediation fL fr.
OAquifer Storage and Recov et7 OSaliniry Barrier if, ti#'d1f34 te}::;'....`:?::::z;>':::z is>::>!i::'
FRO,I To ..............:::: :::::.:
❑AquiferTrct O$LUrmwaterDrainage ft MATERIaI. EMOL4CE(tENTMETHOp
ft
OExperimentat Technology OSnbsidence Control
rr it.
OGeothenttal(Closed Loop) OTracer
OGeotbertnai(Heatiaa(Coolias Rewm FRO. To
❑Other'(explain under#21 Rem atl a) DiscRnnTo�ter Bard sw7tteek Erffi ynq Ku
�yA2422 ft. ft_
4-Date Well(s)Completed-! 1 fc /�ft.
5a.Well Location: O ft. s ft.
ft.
F­llty/Oarer Narne
anlm'm. (if zpptieable; ft. K,
ft.
Phys' 1 Address,City and try T^
ft. `
Coaary `Ci s .....:.:....:.,.:::.. ...:..,:.. :... ..:..::::::.::.::.::.::::.::.:..;;::;:,•:..
Pa-mel Identification No.(PIN)
5b.Latitude and longitude io des•ees/minaresiseconds or decimal degrees: )flfi?f9F1�t'pn pP
(if"cll field,one k0ong is svrTTcicnt)
Certficatiun:
6.Is(are)the well(s): rJPertaanent or O po --1✓ ��,
Tem rary Si_.ar ofCenined well Cotmactor Date
7.Is this a repair to an existingll: n er signing M&)W7n.l herel 7ffr-rer that the,rlft COi was(iwre)<'onstrucred in a,,rdwj,
1w11 we Yes or IlVo /t�:VC?CD2'-.OionOr IS.•1 X6C!12C.n2onif.gatuven0n Standards and that aco,
I)'rhrs is a repa/r.fil/nut kno>+a 4»nrhtrction in(orn!atinn and ernlOis the nuvrr nl tint o(this rrcmV has breaprmided m thr. //or.
repair raider t21 rema,-ks secyon Or an Ike back o(trl s corm.
23.Site diagram or additional wet!details:
8-For Geoprobe/DFT or Closed-Loop Geothermal Wells hating the same You may use the back of this page to provide additional well construction info
consnuction.only I GW-1 is nccdod. Indicate TOTAL NUMBER of was ( 'See Ov ee in Rcmerik,Box).You may also attach additional pages if necessary.
drilled: l
9.Tonal well depth 24-SUBINRTTAL INSTRUCTIONS below land surface:�(�V
For mu/riple nr11s list ail d nits i 7 (fL)ep' ft�erent(ernmplet-3(�20d'«nd_(¢t/00� 'Submit this GW-1 within 30 days of well rnmpletion per the following:
10.Static water level below top of easing:40 24a. For All Weys: Orignal form to Division of Water Resources (DK'R),
1(t cuter Borfew/ehole
a di2 a casing,u•r'+'" (f[.) Information Processing unit,1617 MSC,Ralei�NC 27699-1617
11.Borehole diameter_6 1�6 24b.For Injection Wells:Copy to DWIL Underground Injection Control(IUC)
{jn.)
12.WeD construction method:
Air Rotary Pro-zarn,1636 MSC,RaleigL NC 27699-1636
{i.e.auger,rotary_cable,direct push etc.) 24c.For Water SapD1V attd Opeo-Loop Geothermal Return Wells Copy to the
county®t-ronmental health deparirneDT of the cotmty where installed
FOR WATER SUPPLY WELLS ONLY:
21d For Water�Vetls producing over 100 000 GPD•Copy to DH'R,CCPCUA
13a.Yield(gpm) i� Method of ttst:Air Lift Permit Prv�tatr,1611 MSC.}2aJeagh.l C,27699 16I l
13b.Disinfection type: Chlor. Tabs .4mount 1 1/2 Lbs—�_
Form GW-f North Catalina Department of g
a%irotrmcatal Quality-Division of Water Jtc o,accs Revised(i.6-301X