GW1-2022-07360_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Alfred Kieslmg Sr
F'ROAI TO DE.�CRiYTTO\
Well Contractor Name !i")ft. O
2670-A fL
NC%Bell Contractor Certification Number ..-
>1x:(iFlTER'�A.8N6"
B & K Well Drilling Inc FROM TO D1A.VIETER THICKNESS I MATERLLL
0 fi- I /3 ft- 6 1/4 'a- SDR-21 JPVC
Company Name :...
j 7 b[/ af&:31V�NE&iG:§SLN�>C��'LLSEY�: :,...:zmaf.`".:,: :'�':: i '' :Sti i':<;: i;i':";i
2.Well Construction Permit k:O01-c" �l0 3 ZS T tROM TO DIAV1-TER THICKNESS MAIL:RI AL
Uvr all applicable well constriction permits r-e.U1C.Cowim.State.Pariarrce.etc./ ft. fL in.
i
3.Well Use(check well use): fL
Water Supply Well: F7.:SQiEfifF>
FttOal TO DIAMETER $LOT SIZE THICKNES$ MATERIAL
OAgricultural ❑�MunicipalTublic ft. ft. in.
❑Geothermal(I•leating/C•ooling Supply) 12<dential Water Supply(single) ft. fL in•
❑Industrial/Comm Supply DResidential Water Su pl (shared)
Olrrigation ❑Wells> 100,000GPD FROM TO M.TERrnr EMPLACE'VIENT MLTHOD&.-MOUNT
Nun-Water Supply Well: 0 fL 20 fL Bentonite Pour
CNIonitoring ❑R=occry rr. it.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ;:....::,,,.......;::......::..::..,::;;::;.;.>,:::,;::;:;::::>.»::,.,..:..::••::•::.:.:.:::::::
❑Aquifer Storage and Recovery ❑Sahiiiry Barrier FROM TO MATFRIAL F.MPI->CEMENT METHOD
OAquifer Test ❑Stor'mw'ater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
_
OGeothermal(Closed Loop) ❑Tracer .
lrBRtELiiN& OG'siiac6`aftenl:fass: ci<i;:><t[i::<';:::<:«:::r.;:>;>:::;::'<'
OGeotherinal(,HeatinoJCooliag Return) ❑Other(e.tplain under 2l Remarks) FROM To DESCRI[TION(color.hardn saarroek n artmt sire.err.)
ft. ft. b /q �
4.Date Well(s)Completid- A'/3 2-3—W R it
ell rD# ' ' 111-9//- ,/1 (Jt Q
Sa Well Location: ft. fL e—0 C`J�jljp A� G s(r1 t
ft. / ft. r
� s . {).v_Yma� yet bi �n� rMaw
Facility/Owner Name "— Fag sty s t applicable; ft. fe
4 b \I 6A- �sAy Y.116 I na-0
Physical Address.City.and Zip ft' h-
:?•Zi�RElI#ARli
County Parcel Identification No.(P1N)
lnk{Pli?4c�'1 PP rv'uwAJ n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-ell field,one Iat'lono k sufficient) 22.Certificati n: t
N W _ r l/
6.1s(are)the well(s): OPermanent or ❑Temporary Sij+at Certified Well Contra r re
Br signing this lbnn.!hereby rertifr rhor rite 1:rll(sl,.as(were)ronstrutard in arcordance i:irh
7.Is this a repair to an existing well: ❑Yes or !]No 7A4.-W-4C 02C.010n or 6.4 NCAC 02C.n20o Well Construction Standards and that a com
11'rhis is a repair,fill our knonn well ronsinaaion igfonnaiinn and explain the notury n_f rhr q(this record has bren provided to the v.rll ow arr.
repair raider t21 remarks section or on the back q(ihis 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-i is ncedcd. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages ifnecessary.
drilled: I _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3W (R") Submit this GW-t within 30 days of well completion per the following:
For multiple ur//s list all deptlu-if c1i ferem ferample-3(a�_00'and @1001
10.Static water level below to of rasing•40 24a. For All Wells: Original form to Division of Water Resources (DW'R),
p b. (ft.)
I(n<der/esr/is rthure casing.use. Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
"+"
11.Borehole diameter: 6 1/S (�) 24b.For Injection Wells:Copy'to DWR,Underground Iniection Control(IUC)
Program,1636 MSC,Raleigh,NC 276 99-1 63 6
12.Well construction method:Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county enNironmental health department of the county inhere ulv,aWled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
(gp ) 1.5r Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
I
Form(iW-1 North Carolina Department of Environmental Quality-Division of Warcr Resources Revised 6-6-201X