GW1-2022-09744_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
. I
FROM TO DESCRTMON
Well Courrattor Name ft. 3,0
� D
2670-A
NC Well Contractor Certification Numbers-
:iiL'i:�:O�t•`LE12 _;V"6'`:'
B & K Weli Drilling inc FROM TO DLLNETER THICK-NESS I MATERUL
Company name
0 ft b ft• 6 1/4 ISDR-21 JPVC
_- ... -..•..
991
;::2&3�'+1£REG�tsl�'[fRi�F1SEY�E..,.:.€�sinaf::.::..: `:`3?::i?:<`.�>Z::f.>:i:?.is :;.::� •::'Y::1:.
2.Well Construction Permit�'fQ�60 3 FROM TO UTAM ErER THICKNESS MATERIAL
List all applicable well corrstrucGon permits fix.U1C.(:'ommt Scale.Y'on.'ance•.etcj ft. fL
in-
3.Well Use(check well use): ft. ft. in
.r._
Water Supply Well:
six ::>:::>>[~�::�� "E:::>`i:>>:<>��s:<::•>cs>:::;•::.r >:.<.sir:':;:::.>::
FRONTTO � DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public: ft. fL in.
❑Geothermal(HeatinWCooling Supply) 2<idential Water Supply(single) ft tZ in
Olndusaial!Conlntercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>i00,000 GPD FROM I To yLtTER1AL EtiPLACENffiN-r METHUD&AMOUNT
Non-Water Supply Well: 0 rL 20 ft- Bentonite Pour
Oltlonitorinr ❑Rcc:ovcry ft. ft-
Injection Well:
: fL ft.
a
A uifer Rechaz e C e❑ q ❑ troundwater R mediation _....::..:<.;•,:.::>.;:.;:;.::;.:•:;;>:::.>;:::
O infer Storage and Recovery OSaliitiry Barrier FRO IM y LP#(1 i MATE celile};:>::::;;;:..:;;z<#:::�:•.:.;::.;:.;:: o:a:.:;::•:.:•::::.:::::::.:.:••.:
$ ery FFtOitl TO M1IATER1Al. F.MPL4CEMFM METH(70
CAquiferTest ❑StormwaterDrainage ft. fL
❑Experimental Technology OSubsidence Control fL ft.
❑Geothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(mlon hardness wHlrwk grin sizes ere.l
OGeotbettllal(HeatinJCooling Return) OOther(explain under=21 Remarks) ,try fc. ft.
4.Date Well(s)Completed--9 ? Well TD# Or% ft. /
-J
5a-Well Location: R. fL i t
a�i s �Dh'I m Lt;���i i►S ft, ft.
Facility/OnrerName 11 {� ,,y��FacilityM# fapplieable) ft.
h '1 t — /X ft. ft
Physical Address,City.and Zip ft. ft-
(� 20Zf✓
.:>:tip t:•>:.:�':
County Pa ccl Idctr[ifiution No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees-
(if-ell field,one latrlon.-is sut:rcicnt) 21 Certification: �s
v W42 if ✓ \ 0r (�
6.Ware)the wefl(s): OPermanent or OTempora y S g-aatu.-e Ceniiied Well Cotmactor' Date
Qr signing rhir lbnrr.I hereby rerro:thor the ivell(s)+vas(were)vonsrruered in armrdanre+ride
7.Is this a repair to an existing well: ❑Yes or !]No 19.4 NCAC 02C.010n or I3.4 NGJC 02C.0200 Tr'eft Coratr uction Standards and that a com
!j rhis is a repair:ill our knoer wet!cnnrtractinrr in(nnr grin»and erntai;-,the norure nt'rhe o(rhis record has beenprovided to the v.rll of aer.
repair asides 421 remarks secuorr,or on the back ojrTris form.
23.Site diagram or additional well details: '
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havjng the same You may use the back of this page to provide additional well construction info
construction.only i GW-1 is nccdcd. Indicate TOTAL NrLTMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages ifnece&%ary.
drilled:
/� 24.SUBMITTAL INSTRUCTIONS9,Total well depth below land surface:L!e S (ft.)
For multiple u211s list all depilu'iifea fecent(Grample-3(a100'and 2@ 001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing:40 24a. For All !Fells: Original form to Division of Water Resources (DWR).
(ft.)lj nrAer level$shove casing.use"+'• Information Processing I'Uni 1617 MSC.Raleigh ATC 27699-1617
11•Borehole diameter•_6 1/8 ( ) 24b•For Injection Wells:Copy to DWI-Underground Injection Control(IUC)
ry Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rota
(i.e.auger..rotary_cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county enrironmental health department of the county ttd)ere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DVi'R,CCPCUA
13a.Yield(gp lu) -it) Method of test:Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1611
13b•Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of En.ironmcntal Quality-Division of Water Resources Rcviscd 6-6-2019