GW1-2022-07268_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesltng Sr ,�..�:���. ........ . ....:.::: ,..........
FROM TO DE.aCRn'7T0�
Well Comrec[or Name R, ft- �,V
2670-A FL ft. p 2
NC Well Contractor Certification Number 45OEt`.1:FSZi:•' N�: uii:'IDt�i�sed'isells DR:3ftS'QE�2 ! .."1�:�i�:'.>::i:::z:F(:::i;:
B & K Well Drilling Inc FROM I TO DIAMETER THICKNESS MATERLt,L
Company name
p ft- I 1 ft- 6 1/4 i in- SDR-21 PVC
2 _..... ... ............:.::..::..:..::;�t>:'::.'.:.:::.:...:::
�.�� �` 2&3�li�BRiG§S1htE'(IR LIS l cekhexm THI RI
2.Well Construction Permit# Ixonl r0 UTAStI rER THICKNESS D1altiR1AL
List nl/applicable wall cartsrnt('tiarr permits fix.UIC,Corurrv.State.i%ar.'ance.arcJ (l. ft.
In.
ft- fc in-
3.Well Use(check well use):
Water Supply Well: 1:ZSQiE&1`z -
FROM I TO I DIAMETER SLOTSIZE• THICKNESS MATERIAL
O.Agricultural OMu nicipal/Public ft. rL in.
DGeothermal(HeatinJC'ooling Supply) l<dential Water Supply(single) R. rL in.
OludustriaKorrimercial OResidential Water Supply(shared)t
O Irrigation O Wei Is> 100,000 GPD FROM TO MkTERIA1. I EMPLACEMENT METHOD&AINIOUNT
Non-Water Supply Well: O fL 20 fL Bentonite POUT
0mottitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F,M PI-4CEMENT METHOD
CAquifer Teat ❑Stormw'ater Drainaee R. ft.
OExperimemal Technology ❑Subsidence Control FL ft.
OGeothermal(Closed Loop) ❑Tracer ':BR1LLi3�fG14Ts�ttack'aiedldiaix;<;;::<;:.:::;:;:z.>«::::<•;::s<:;,:;;;;:: .<
❑Geotbermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DES IPTiON-for.Aardnesssr rUroek £txm size.KC 1
ft. ft.
4.Date Well(s)Completed e11ID# fc. J^ f<. � (�
Sa.Well Location: ft. ft.-rwDIIL�
'N'tbA Y
A �n t,5
Facility/OwTerName Facility T "61'applicable,' ft. ft-
jo Al
t l✓ . ft. I ft.
Physical Address.City.and ZL ft' ft 1n&-fonatio:l PircC30mg Ufxl
County Pawl Identification No.(PIN)
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees-
(if-ell field,one lattlona is%ufcicnt) n—Certifica•on:
'!/
6.Is(are)the well(s): IInPermanent or ❑Temporar}' _ fCenitied well-Contractor ate
Brsignin.-this fomn.1 herebr cirri)�that the.mll(s)evens(rcere)cons (Ted in ar cordanre pith
7.Is this a repair to an existing well: OYes or !]No 73.4 NCaC O'C.oion or/S.4 ACAC 42C,0200 Mell Corutruction Standards and that a earn
lfrhis it a repair.fill our known.well t,nnsrnection infn7rno0nn and ern/ab-.the nature nfrhr nfthis record has burn provided to rho rr/1 or ner.
repair raider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is nccdcd. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:—Z,*& (ft.)
For multiple gills list all depth'ifd(fferent(e-rumple-3(ar_00'uoet 2@1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For Wells: Original form to Division of Water Resources (DH'R),
10.Static water level below top of casing:40 All Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
!1 trvler eerie is above erasing,use"+" '
11.Borehole diameter, 6 1/8 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county enrironmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to D%\-R,CCPCUA
`13a.Yield(gpm) Method of test:Air Lift Pcrmit Program,1611 MSC,Raleigh:NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of En,ironmcntal Quality-Division of Waxer Resources Revised 6-6-2019