GW1-2022-07287_Well Construction - GW1_20220809

WELL CONSTRUCTION REGARD fGW 1
For Laremal Use only:
1.Well Contractor Information:
Alfred Kiesling Sr
cVe11 Conrrettor Narrx .......:, ......................
2 FROM ro
670-A D��o` ... .. ........::::::.::.:..:..:
1 Osf° Z,V &5-
NC Well CoMnIctor Cerrincation Number
1 b yF
B & K Well Drilling inc FROM To D>a
Company Nava 0 fit. I f- 6 1 I�� THIC'KN@$S IVLa7ERLr,I
/ %'st;&: $• . is
SDR_21 PVC
2.Well Construction Permit TM:
LLrr rJl applieablu well corzrmerGa.r perms-:.c.UIC.Lorurty.Srare.tmn.'ancc.a ETzonl r0 ULLMhTER TraCKNFSS MATERIAL
r</ ft.
3.Well Use(check well use): ft. i
ft iv
�Vater Snpply Well:
X.
Fxonl.culttua! ❑lriunicipal/Public To otAMereR .,.._. ;GL07 SIZE THICKNESS MATEWAL
OGeothertnai(Ileatii1UiCoollllaa41P.S of ft. ft in.
Y) �dential V1zt�-Supply{single i
❑Industrial/Contmerciai ft• fL in
OResidential WaL•r Supply(shared) ;.;..
18i:7t. .
Olmga[ion i3Es'Fasz <asE :>> ;;;;E:i; 2:::iitdi;::;isi>>:^::;:;;ti::;
OWelts> 100,000GPD lxont To :::::::.::.....::;,::::::..;.:: -
Nun-Water$apply Weft: 'rL�IERinr E*1PI.ACE�TMETHUD&.4�tOUNT '
LIMonitoring 0 2 20 f` Bentanite Pour
ORcc oc cry
Injection ReIL• ft. it.
OAquifer Recharge GtGroundwatet Re-mediation
ft fr.
OAq_uifer Storage and Recov ?&alia:ytq ^'=
�Y OSa!ittiry Barrier FROM TU )2; ::>::>='?:;:<`'•><:{j::;:;>.i<:#: :: :: ``:::>[> %>`;x >:<.
OAquifer Teat OStorm%vxer Drainace ft PL>TERIA I. PMVL>CFJHfNr MHTHOp'
ft_
❑Experimental Technology OSubsidence Comm] ft.
❑Geothermal(Closed Loop) OTracer it. atl�Aen
>2�'� .id3!rf� U�:'atFschDE5CWP17 :...:. .....::.. ..:..,�...,
OGeothermal(HeatinJCooling Return) OOther e. lain under= FRonr (s' '3<``:'s`::;"s<<"::;i?s•>::':::<:a;;::.
( tp 21 Remark) To O\(oobr.tm,lness sa7/roek
r.� / tr»sizes ercl.
4.Date Well(s)Completed_-JvZ�2-3ell
y C✓'� � �!j
1D#F S .
ft. C ft
Sa Well Location:- ft. J ft. I
®O f4 / ft. i
Far.rlrty/On�r Narne --�---
Faciliry MF 0fapplicable; ft. ffi
fL
Physical Address,City.and Zip
fr. fL
rd .022
c
County PaL=l ldentiEcarion No.(PW)
5b.Latitude and lona-itude in degrees/minatesiseconds or decimal degrees:
(if-oil ftc)d,one Wong is suficicnt)
22-Cerri&cme
6.Is(are)thewell(s): inPerrnanent or ❑Temperarc• 5_tee* fCned Well Coaeec or
Dare
7.Is this a repair to an existing Well ❑ Br signing;kslotm.1 hrrPh•tr fife mcr rev r:Pll!s1 rcns(tear Co
in ercordmx•o::rrh
Yes or �No !S4:VCrC 02C.010n or 75.4 A6C 02C 0200 1;eR Cortcaveliorr Standards and r&v a com•
if rhu is a repair.fill our knonT well<»nstrucrion i,�fo�na inn and ern/ai,-ri a nuvry nt rnr o_f t ns mcm-d has lien prm-ided m rho—11*owns.
repair rarder 42/remar kx seavon or on The back o(trn$,arm.
i.Site diagram or additional well details:8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
consnuction.only 1 GW-I is nccdod. Indicate TOTAL ITUMBER ofwclls (add'See Over'iu Remarks Box). attach additiomal pagta if You may also necessazy-
drilled: f
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land sarface:_�p s
For mulrtple urihs list ail depths if&ffrrrm(eromple-3(c200 .!'an 2@1001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 ) 24a. For All Wells; primal form i to Division of Water Resources (DWR),
!%ur lei legal is shine coring.rue (ft' Information PtocZ5 g Unit 1617IvISC.Ralei ATC 27699-1617
11.Borehole diameter.6 1I8 24b.For Injection Wells:Cony to DWR Undertgrotrnd Injection Control(TUC)
(in.)
12.Well construction method:
Air Rotary Program,1636 MSC,Raleig�L ITC 27699-1636
(i.c.auger,rotary.cable.direct pink 24c.For Water Sa OnLoon Geothermal Return Wells Copy to the
county®,zronmemal health departmemr of the county u$ext trL,tailed
FOR WATER SUPPLY WFi i c ON Y:
24d.For Water Wells producing over 100 000 GPD Copy to DN`R,CCPCUA
13a �Yield(gpm) � Method of test Air Lift PermitPro_nrr,1611 MSC,Ralttgh_NC 27699 161 1
13b.Disinfection type. Color. Tabs amount /2 LbS G
Form GW-1
North Carolina D�Tarrmcnt of En,iroamcntal Quality-Division of Ware RnoutcCe
Revised6-6-019