GW1-2022-07282_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
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Well Coutracror Name OAI TO DE.SCRiPITp\
2670-A rt. f(. p 0 S
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NC tt%ell Contractor Cerrification Number
B & K Well Drilling Inc .....t :: : g:Elm
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TO DIAMETER THICKNESS MATERL-,L
Company Name 0 ft. ( ft 6 1/4 in SDR-21 PVC
I G� 3>} 1 11 RdG§SE19Fs`1�R F)SDr ..,.,.....��'
2.Well Construction Permit�: { / 1xOnl 3"?`:":`AT
UTAt1ErER THICKNESS MATtiRiAL
Lis,all applicable%t,11 consr dr4ion permits .e.UIC.cowa.sinie.Yaranec.etc.) t in
3.Well Use(check well use): k- I ft in.
Water Supply Well:
FROM TO O DIAMETER SLOT SIZE THICKNESS MATERIAL
?.gl-icultura! OMunicipal/Publu ft, ft in.
❑Geothermal(HeatinJCooling Supply) 2<dential Wat,Supply(single]
ft- fL
❑Indusaial/Cominercial OResidential WaL-rSupply(Shared)
Irrigationqk
❑Wei Is>100,000 GPD FROM TO MATERIAL ExiPLACE�tE,7 METHOD&iNl0U- t
Nun-Water Supply Well: 0 fL 20 IL Benton ite Pour
❑'ifonitoring ❑Roc:occry ft. fL
Injection Well:
OAquifer Recharge ft ir.
OCiroundwater Re-mediation
OA uiferStota eand >i&?53yC#'dif3i6f:..;:> IeY`::>::::"?:::::;'ii><;:is; :::.<:fi:i?::;;;;:;:>a;:>a»»i»:
q _g Recovery OSalitnry Bamer ::..::.:::...
FROG( TO MATERIAL EMPIACEI(1FNf METHOD
❑Aquifer Test OStormwater Drainage ft ft.
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer
t991�L3-
❑Geothermal(Heaike(Cooline Return) ❑Other(explain under#21 Remarks) FR Af TO DESCRFMON(whir.hardness, er mi aza etel
ft ft. _ ®r
4.Date Well(s)Completed- ell ID# a, ft
5a.Well Location: ,�,, ►// t. ft
"_cam-LJict r 1 d t/S
Facility/Owner Name Facilitylt)>(ifapplicable; ft. ft- " v
„t
.ems NopiQ�-,Al� -
ft• ft
Physical Address,City. id Zip ft. fe AYG 4 v
l�
County Parcel Identification No.(P1NI) .MVQi80G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if w•cll tield,one latllong is sufficient)
22_Certification:
\ R .....
e
6.Ware)theweil(s)_ �Permanent or OTemporary- Signature ertitied WellCo¢aac:or Date
Brsigningthislorm.lhrreh!•(•rrtifrtharreri:r(1(sli�s(tcrrr) onstrrrtted.narcrrdanrt;:irh
7.is this a repair to an existing well- ❑Yes or �V o 13.1 NC4C 02C.0100 or d4 Nek.72C'.0200 tre11 Cortrtrudion Starufards and that a evm!f rhis is a irpair:fill out knora»ell<wnsmuc)ion informarinn and explain,the narurr nfrhr afritis record has been pros-ided m the•.r/1 owmer.
repair under#21 remarks secaon or on the back ofthic form, -
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haying the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is ncedod, Indicate TOTAL N7LTMBER of wcils (add'See Oyez'in Remark,Be-,).You,may also attach additional pages ifnecessary.
drilled:
cL� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1�7C7 (�)
For multiple nr//s list rJl JepJn if diffetrnt(ernmple-3(4=00'ant t 2(d1j 00� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing:40 (ft) 24a. For All Wells: Original form to Division of Water Resourom (DWR).
Q"iirtrer level it uboi r casing.use••+'- Information Processing Unit,1617 MSC,Ralei&NC 27699-1617
11.Borehole diameter: 6 1/8 On-) 24b.For Injection Wells:Cony to DWR Underground Injection Control(IUC)
Air RotaryProgram,1636 MSC,Raleigh.NC 276 99-1 63 6
12-Well construction method:(i.e.auger,rotary.cable,direct push.etc.) 24c.For Water Sin typp and Open-Loop Geothermal Return Wells Copy to the
county ennrontnental health department of the cotmty where in,rolled
FOR WATER SUPPLY WELLS ONLY:
2 td For Water Wells producine,over 100 000 GPD Copy to DN'R,CCPCUA
13a.Yield(gpm) Method of test:Air Lift Permit Prn�an, in,I MSC,Raleigh,NC 27699 ibl 1
13b.Disinfection type: Ch1Or. Tabs Amount: 1 1/2 LUS
i
Form GW-1 North Carolina Department of En.iroamenral P Quality-Division of Warcr RcsourcCe RcvL cd 6-6-201 K