GW1-2022-07276_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(Gw-l) For h2temal Use Only
1.Well Contractor Information:
Alfred Kiesling Sr
well co'.M.
To ?JT
FROM?1%1 DUC_.MON'Pt
2670-A
V L
NC Well Contractor Certification Number
TO '10
B & K Well Drilling Inc 10 9� i_DLA_N1ETE,7RL l)MTHJ(JNESS�M:R**L:*A'L
Company Name 16 V4 in ISDR-21 JPVC
2.Well Construction Permit#: (3 3ePPLT6 FROM I TO DIA-ME'RERP I TRICKNESS
AtAIERtAI
Lit all OPPIXdhk well emstrucdon permits,;_e.L11C.co­rv.State MC,*o,,C,-.wC.) I ft. i ft. in.
3.Well Use(check well use): ft- I in.
Water Supply Well:
I DIAMETER SLOTSILE T ICKNFSq -MATCRIAL
f N
0A.gricultura! 0-MUn' iPaVPLbliC FFIRONT rL
I is
rmal(HeatillaiCoolilig Supply) de7itial War- Sul
OGeothe ly) a< v )Ply(single]
ClUdIISM&COmmercial CResidential Wateer Supply(Shared)
01rrigation
0 Wells> 100,000 GPD FR NI DiPLACKMEN r rdmoD .Motto
Nun-Water Supply Well: 0 20 nite Pour
ONIonitoring OR=ovc-.v
Injection welt:
CAquifer Recbarge LIGroundwater Remediatior.
OAquiler Storage and Recovery Maliuiry Barrier FRO,'%l
TO NLATERIAL I EMPLACEMENT METHOD
Aquifer Test CStormwater Drainage ft. ft_ I
OExperimental Technology 0SUbsidence Control ft.
OGoothen-nal(Closed Loop) OTracer
0 L fL'Gg:k T CGeothermal(HeatiELS(Cooling Return) 130the,(explain under#21 Remarks) FROM MT01 D&SCRrPT10'N(wJo,hrdn�:gWr-k Mn R­Sim nu
4.Date Well(s)Completed- eU rD# ft. t. s-ev—e, t_S
5a.Well Location: ft.
Z F_ "- Iry "6-ca ��Kdp&� _T
14 .dL ft. it. t
FacilitY/Owrerhlarne Facil4tv Ml�(ifzppj;cable�
fr. fe
Q,A ?4e'f
Afewy*15') V M U
Physica!Address.City.and Zip 9 1 ft.
A I IL.411_ 'An99
Couary
?amcl Identification No.(PLN) kgogajakn PrncoGs jng Unt,,
56.Latitude and longitude in degrees/minatesiseconds or decimal degrees: MAVQ180G
(if-ell field,one latJon,is suflicic"t)
22 Oct LM cati n:
W 0 1 1 7—
6-is(are)the well(s): OPermanent or OTemporary SiParurcgccnzificd Well Coaz=or Date
*r I herei*r re,7.:mar rile.:rll rsl,.as Nere)constructed accordance with
7.Is this 2 repair to an existing welh r_.-Yes or !]No 15.4'VCJC 02C-010r or 15-41,1,'CAC 02C.0200 IMc/7 Coacmerion Standards and that a corn
L1*rhhvix a repair.fill our knonr well e infol Mofin,,and explair.,h,, ffh�s record has bernprmided ro the­fl o­rr.
repair rarda,#21 rem&,-kj section or on the back ofthislorm.
23.She diagram or additional well details:
8-For CAvprobe/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 I GW-11 is nccdod. Indicate TOTAL NUMBER of wells (add'See Ovee ju Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL rNSTRUCTTONS,
9.Total well depth below land surface: UL)
Fur-m u iziple i t VUS list lid[depths if&ffc renr(crumple-3(5�2 0 0,(In'l 2 0 0�J Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For All Wells: Original form 'to Division of Water Resources (DIA'R),
ff"'Iter lew/is abol'r casing,use- (ft*) Information Processing Unit,1617 MSC.Ralei&NC 27699-1617
11.Borehole diameter: 6 1/8 1
24b.For Infection Wells:Copy to DWR_Underground Injection Control(rUC)
Proz-arn, 1636 MSC.Raaeil;:�NC 27/699 1636
12-Well construction method:Air Rotary I -
(i.e.auger,rotary.cable.direct push etc.) 24c.For Water Snppiv andOwen-Loop Geothermal Return Wells:Copy to the
county enNironmcatal health department Of the votary where,ilLstalled.
FOR WATER SUPPLY WELLS ONLY: 71
24d.For Water WeRs producing over, 100.000 GPD:Copy to DWR,CCPCUA
133-Yield(gpm) Method of test. Lift P—,t 161 1 MSC.Raleigh-N i C 27699-1611
13b.Disinfection vjN: Chlor. Tabs .kmount: 1 1/2 Lbs
Form GW-1 North Carolina Dpanmcnt of-En,iro cL=nral Quality-Divisiou of NA'aTcr Kc.sOL=. c.q Revised b-6-2019