GW1-2022-07361_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For intemal Use Only:
1.Well Contractor Information:
Alfred Klesling Sr
FROM TO DESCRiPfIO."
well Coutrattor Name
• n.
2670-A
NC Well Contractor Certification Number ���� - � �-
la:E)F)TE12eNl ac>niirca�ed$rlk: g'1tkER ':::::.... r :;>:.;<='vEi':<'
B & K Well Drilling Inc FROMI T� D1AMMETER I THICKNESS MATERIAL
0 ft. I ft. 6114 '° SDR-21 PVC
;<:2��iG1VER:
Company Name .:
.. ....:,:_..::::::..:..:...:.�. ....::.:....::..
�f G: �::(�i�'f3SE�. ...
2.Well Construction Permit# �f ri6[�G-/�3 f�rD d2 Fxo•t To1 DIAM rER I THICKNESS MATERIAL
Litt all applicable well cotti'trvClion prnnits 4.r.UIC.Corurty.State.i%ar.'antc.rrc.) ft. I ft. '..
in.
ft.
3.Well Use(check well use):
Water Supply Well:
FROM TO DIAMETERI �LOTSIZE THICKNESS MATERIAL
DAgr cultural OOMunicipal/Public ft. ft. in.
❑Geothermal(HeatimdCooling Supply) BResMu�rdential Water Supply(single) ft. fL in.
OlndustriaVConmtercial ❑Residential Water Supply(shared) ....
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMIPLACEMENT METHOD&:-MOUNT
Nun-Water Supply Well: 0 fL 20 fL Bentonite Pour
Omonitoring ❑Ruovcy rr. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _....,.....:._..:..;.:....:.:;•:..:;:.;..>.<s;<ss:>:a:;s>i;:a:> .:
OAgtufer Storage and Recovery ❑Salilticy Barrier FROM TO MATERIAL EMPLACEMENT METHOD
C Aquifer Test ❑Stormw'aterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 'ER1LtiiiSTGLUG_ataicbad�ttied3>eeces�srr.:`::>:>:'>::`i>
❑Geotbermal(HeatingtCoolke Return) ❑Other(explain under#21 Remarks) FROM To DESCRtPTfON lw5 Hard sotvrotk atom s etel
ems,J
4.Date Well(s)Completed- g&jpZZ Well ID# ft. ft. !(/�(/ ✓� 0 /
t
ft. fL 1
Sa.Well Location:
���rr `�1rYM1Q��l � i�►1 ft. ft. A
Facility/Onrer Name
Z-, l 1! Facility M#(ifapplicable; fr. fr- /�-
7 817,7 <S 12s Y y r fr. ft.
r 9Y G� � ��ttr]f �� /p7lJ t
U
icaI Address,City.and Zip fr' fr
County' Parcel Identification No.(PLN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D, Q/BOG
(if-cll field,one lat long is sufeient) C
2.Certificati n:
N W
6.Is(are)the well(s): OPermanent or ❑Temporary - arm fcenified Well C.bntractor bate Q
Br signing this 1bi7n•l herehr rer7ift that the+:rll!s/seas(were)ronstrucred in arcordanre idrh
7.Is this a repair to an existing well: OYes or nNo /s.a:VCAC 02C.070n or 15.4 NCAC 02C.0200 Wdl Construction Slandards and that a com
lj rhls is a repair.fill our kno>n well construction infonnorinn and exn/air the aarurr nl the o(thic rrenrd hav been providrd to rhe'rrll on.wer.
repair raider+`'2I remarks section or on the back orrhis corm.
23.Site diagram or additional well details:
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of w+clls (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 �/ C 24.SUBMITTAL INSTRUCTTONS
9.Total well depth below land surface: . o9 TJ ( ) Submit this GW-1 within 30 days of well completion per the following:
For-mulripie uLlis list till depdts if efi ferenr(example-3(ar:00'and 2(dt1001
10.Static water level below to of easing:40 24a. For All Wells: Original form to Division of Water Resources (DW'R).
p (ft.)1(nvler-lewl is abu+'e casing,air Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
11.Borehole diameter:6 1/H 24b.For Injection Wells:Copy;to DWR Underground Iniection Contra!(IUC)
(in-) Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
Re.auEer,rotary.cable,direct push.etc.) county ewironmenral health department of the cotmry where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodncink over 100.000 GPD:_ Copy to DW`R,CCPCUA
13a.Yield(gP lu) L 5 Method of test: g Air Lift Permit Pro arn,1611 MSC,Raleigh.NC 27699-161 I
I
t
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
i
Form GW-I North Carolina D Tanmcnt of En,iro°mcntal Quality-Division of Warcr Rc ourccs Revised 6-6-201 x