GW1-2022-07278_Well Construction - GW1_20220809

WELL CONSTRliCTION RECORD (GW-D For Internal Use only'
I.Well Contractor Information:
Alfred Kiesling Sr :
Well Comma- FRO of TO DE..qC:RIPTCO\
2670-A I ft• rij ft. ,V
rL L vs fit. � Ire NC Well Cormactor Ceniticat on'umber
B9
« K Well Drilling Inc FRODt TO I DL4V1£TER THlC7C1E55 MATERLIL
Company Name 0 ft. 6 ft• I6 1%4 in- SDR-21 PVC
2.Well Construction Permit R: 1 FROPI r0 DtA.wE rER THICKNESS MATERIAL
Lit,r<!1 appl'ecb/<•weUcUli•;7T,rrlian prrrn!LS Corurrv.suite,t%or:once.r:C.j I ft. i fr-
3.Well Use(check well use): ft. i fL in.
Water Suppiy Well: L7_51::f
fltONi I TO I DIAMETER SLOT SIZE TXICKNESS MATERIAL
OAgr cuhu'21 OMunicipal/Public ft. I fL I To.
❑Geoth2mlai{,1eatiilJCODlilla Supply) dattial Wara Supply(sing) j
it. fL in-
❑lndustriallConuuercial OResidential Water Supply(slimil)
I Dwells>100,000 GPD FRvOf To �L\lERInL EsLPI.1C �7 ME78UD&.L�tUiM
Nun-Water Supply well: 0 tL 20 fL Benton ite Pour
OAlonitoring ORc:ovcry
tr. tt.
Injection RtelL•
OA uiferRechar`e ft. ft.
9 OCiroundwater Remediation
OAqutfa Storage and Recovery OSaltittty Barra �R3. rt 3'4f3�.F iel,:::..:::.::.:.::,.:..:::..:;:.;:.:::.::.::>:::.:.::•::::.;:-:.:.:.>;:>;:-.:
I�itUm TU t•LATERiAr. P,MPt-ACEItiFJVT METHOD
OAquifer T&st OStormwater Dreinaee ft. ft-
Technology ❑Subsidence Control
❑Geothermal(Closed Loop) OTracer
LIGeothermal(HeatiaJCooliag Re IM) OOther(e-plain under#21 Remarks) FROPf To I DEPAOUPTION(mior.h2rdtHrz.sowrtick gtmi site<rc�
4.Date Well(s)Compileted::7 ! x Well Ill# JC ft. t ft. ` ' �✓ LD
Sa.Wed Location: /ze
7' s ft. ft. f/
Facility/Oarer Name FacilitY MF(ifapp1;cable'. ft- M.fL s
/ i r L-
lci-( ft.
Physical Address,City.and Zip ft. I f L
RR7r�iii:i'>i
7 .
Coon» aa_d Identification No.(PIN)
5b.Latitude and longitude in degrees/minatesiseconds or decimal degrees:
(if-all field,one latllon.-is sui;tcicnt) C
22-Certifi 'on:
6.Ware)the we(1(s): OPermanent or ❑Temporary- S;g u- fCerzined Well Contzctc, Date
41'signing tksfbizc.iherert•rr,A:that rive l:rll!s1 ivas(leer&/<onsimcred i'n a<cvrdmire::irh
7.Is this a repair to an existing well; OYes or �.No 15.4:VC4C 02C.010r or 75.4,`VC.tC 02C.0200 TVefl Coitc2a&0;z Standards and that a corn
if rhav is a repair.111 our knona well<»netna tirnr in%nr arinn and etn/air,rite naoarr of me of ribs rrcnrd has lxrn prm iced ro rhr+all o+.rcr,
repatr atrder#21 rgaa::Es secton or on the back of Eris 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 i GW-1 is nccdod. Indicate TOTAL NUMBER ewclis (add'See Ovee iu Remarks Bm).You:may also attach additional pages if necessary.
dr led: I
// 24.SUBMITPAL INSTRUCTIONS
9.Total well depth below land surface: OL)
For multiple ur((s(isr all dep&-ifttfferent(trample-3(c_00'anal_'(d1100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of a ing:40 24a. For_U Wells: Original form;to Division of Water Resources (DWR).
(ft.)!%outer(aril is uhme casing,use IDfotmation Processing Unit,1617 MSC,Ralei_b.NC 27699-1617
"
11.Borehole diameter:6 118 0-) 24b.For Injection Wells:Cony to DWR Underground Injection Control(IUC)
Aotary Pro2atri,1636 MSC,Raleigh,NC 276 99-1 63 6
12.Well construction method: lr r
Re.auger,rotary.cable.direct push,etc.) 24c.For Water Supply and Open-L6op Geothermal Return Wells Copy to the
county environmental health department of the colmry where it swied
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100.000 GPD•Copy to D A R,CCPCUA
13a.Yield(gP )m � Method of test Air Lift I Permit Pro_rarr,,1611 MSC,Ralatgit.NC27699-[6I l
{,
13b.Disinfection type: Chlor• Tabs Amount: 1/2 Los
Form GW-'i 4
Noah Carolina A'panmcar of En.irotrarenral Quality-Di�sioa of Ware-,Rc:oicca Revised 6•6-301x