GW1-2022-07269_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD (GW-1) For lntemal use Only-
1.WeH Contractor Information:
Alfred Kiesling Sr
FROM TO DESCRTMON
Well Contractor Name
2670-A ft�a ! V 51I `
NC Weli Contractor Cerrificat;on Number ...'....`....:::......
15 EiFt`FF�F�t.Si�tG`t>I'ermi>tomes§edYel�1�$'�E-tQ£1?`fIC� .+n?:
B & K Well Drilling Inc FROM ' TO I DIA.YiETER THICIMNESS MATERL L
ft. i ft- 6 1l4 in- ISDR-21 IPVC
Company Name h I:;:, :>
i ?1c31?4 R':G§SEItiF i(�R FfSE ringTIER...., ..
I•x011 TO 1 DtA11 E--rEK THICKNESS 115ATER1:1L
2.Well Construction Permit�: ft. ft.
List all applicable mall constriction cc—nitT 4.e.771C.Carom.State.1%a^arr_t'.
3.Well Use(check well use): I
Water Supply Well: FKOnt r0 I DIAMETER I SLOT 512E I rH1CKIRE55 I MATERIAL
OAgticultutal OMunicipal'PubLc I tt. ft I is
C.-Geothermal(HeatiuJCooling Supply) dcidcntial Warta'Supply(single) ft. ! ft I iuz
Cln dusir.aI Conun ercr21 ORe sLenn al Water supp
ly ly(shared)
Glrrioa[ion ❑Wclis> 100,000GPD FROM . TO
' rLnTERLrsL. EA)1pLACE�tn7 MELBUD&.i�fOUN7 i
Nun-W2ter Supply Well: 10 ft 120 ft- IBentonite (Pour
❑itlOniTOring ❑Rmovcry ft• I
Injection Well: ft. ! ft. I i
A uifer Recharge OGroundwater Remediation
OAQu fifer Storage mid Recovery ❑Salinity Barrier FROM To r NIATERIAi i FMPI-ACEMFTT METHOD i
CAauifer Test OStormwater Drainage. I ft. I ft.
OExWmemal Technology ❑Subsidence Control I ft it•
s:
OGeothermal(Closed Loop) OTtacer
FROM oc
TO DESCRtPT10N(color.hardness rk fr=Size.Ke 1
CGeothennal(HeatinJCooling Return) OOther(explain under*21 Remarks) r
4.Date Well(s)Complet :.6,%&�;;'Well M# �( it. Uh/ iv !s/ Y
ed
C� R. ft �y
Sa-Well Location:
(�
n L 6 T _�dYY1 z S
FacilityloerName Facilitv Ml p e;(if I fir. j ft
an a, N
I
6 l ii i
Mwical.Address.City.and Zip j ft. I f, i -Q Jn77
T
C ' ` ?=cl ldcntiff=iun No.(PLN) i Int'j i.'3uen Pr^"SDang Ung
. � Di'dt.2f30G
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if-ell field,one lat/loo.is sufcicno 22.Certification-
. Wav"U.P 60
6.is(are)the well(s): nPermanent or 0-TemporarySiva e
afCa i i `Well Con�ntor
4
rh--rll(si+•as( 'ern)ronstrrrted!n arcrordmrer:nth
7.Is this a repair to an existing well GY"es or "-No r ._. rFL vjor or i5. tC C+?1C.0100 T sit Couctruccva Standards and that a CaP
ar -hv record has.seen Pr or(ded to rho> /1 o mrr.
tl�h s a a repo r.fill nut knahn Nell onnrtrarn'at mfcnrar.'nn end ernia,7. ra ror�rr,x'a
repair rarde-421 remarks section or on the back oriltur form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having-the samz You may use the back of this page to arovjde additional wei]construction info
constriction.only 1 GW-1 is needed. Indicatc TOTAL NUivTBER-of-clls (aed'See O`'ee iu Remark;Box).You may also attach additional pages if necessary.
drilled: _/� 24.SUBMITTAL INSTRGCTTO-S
9.Total well depth below land surface: —_2q uy JQ Submit this GW-1 within 30 days of well completion per the following:
Fur mu(ripie n'r(ls list ill depilu'ifthfferrnt(trample-3(a::00'
10.Static water level below to of casino•40 242. For AA Wells: Original 'form to Division or water Resources (DWR).
p =• (ft.) iDsormation Processing unit 161?MSC.RaleighNC 27699-1617
f miter level is dbore casing.are"+
11.Borehole diameter:6 1/8 liar) 24b.For Injection Wells:Cony to DwTL Underground Injection Control(IUC)
Prog arn-1636 MSC,Raleigh,NC 2 7699-1636
I
12.Wen construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the;
(i.e.auger,rotary.cable.dirccr push,etc.) county em:ronrnenral bealth department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 124d.For Water Wells prodacilia over 100.000 GPD:Copy to DWR,CCPCUA
�/h�
Air Lift Pc;rnit P-o�m,1611 MSC.Ralttgl.ivC 27699-10L 1
13a.Yield(gpnt) Jc Method of test:
Air
Tabs 1 1/2 Lbs
13b.Disinfection type: Amount.
C
Form GW-i Nora Carolira Dcpartmcar of En,Ton;rr•azi Quality-Di visicn of Water Ste our­es Revised"-201 K