GW1-2022-09852_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-11 For lntelnal Use Only:
I.Well Cootraetor Information:
Alfred Kiesling Sr
Well Cou ractor Name FROAf TO DLe(1ZTM0?
2670-A ?? ft. �-sS_ i�c�/ 1jj 0X0:5� /r
NC Noll ContactorCenifcationNumber '' { J ft_ I I /%
isiL-x;<3FxTE$:•f3'�Sinif"i..:.`m�raseiF:.....:�g:f #it:::
B & K Well Drilling Inc FROM I TO DLAMtETER T91C3(.NESS MATERLA
Company Name �j O ft '71� ft. 61/4 L° SDR-21 PVC
2 1.. uoF D ��� :FRO
_Well Construction Permit,':_ I TtOnl I TO DtA.vIETER•• THICKNESS DiA'itR1AL
Ltrr all applicable well COustnsction perrnitt,5.e.L7C.Cora rv.State.Variance.erc•.J ft. I fL in.
3.Well Use(check well ace): fc ft.
_....... in_
;a :...:: :>..............Waier$nPP1vWel " ::.c . .
'
FROM I To I DIAMETER I SLOTSIZE TKICKNF$S MATERIAL
0-Agricultural ❑Municipal/Public k. ft to
OGeothennal(HeatingiCooling Supply) 2<idential Watts'Supply(single) IL
iu
Olndustrial/Contmercial OResidential Water Supply(shared)
..............:...:...........,....... ::.
01rrigation ❑Wells>100,000 GPD FROM TO MATERIAL LAIPLACENtENT METHOD&.010U.rr
Non-Water Supply well: O f� 20 f` Berltonite Pour
CNIonitoring ORcaovcry
ft_ ft_
Injection Welk
OAquifer Recbazae O(iroundwater Re-mediation fr. ft.
OAgtrifer Storage and Recovery O.SalnliCy Barrier FROM TO MATE121A1. EMPLSCEI(Ik1Yr METHOD
GAquiferTest ❑StarmwaterDrainaee ft. fr_
OExperimental Technology ❑Subsidence Control fc ft.
❑Geothermal(Closed Loop) OTracer
: >s>��F{sL;31VG��CC�aitacti'a&�tiiiisE: :#=eecessatv}>-:::%�>�`::�::::t:�:<:::<?><:�>::�i�:::>r:�•:'<
O(ieothetmal(HwtLmaiCooling Return) OOther(explain under=21 Remarks) FROr-t To DLscRIPTro�(ter rmk ,��H.l
O ft ft. _p
4.Date Well(s)Completed- Z2--ZVell1I3 �3 ft. ft- _t^
5a.Well Location:- 3 tt. fc y r J iz C L
Aorni-, ft. ft. n ✓
Fa,:�lrty-/paTerName FzcililyMl"(ifapplicable) ft. it
��� /• y / ft 'g g
��d •fir,t—
°�...0 t4-s.9 `ttZ`x..,F•„i
Physical Address,City and Zip ft. ft r U
County Paz celIdentification No.(PIN)
5b.Latitude and lonaQitnde in degrees/minutes/seconds or decimal degrees: 17
v��jl�i`'rDka
(ifwcll tield,one lat/long is sufficient) 31 Certifies'on- ` (`
6-Ware)the well(s): Permanent or OTemperars' Y-atar-- fCatitied Well Cotmactor to
drsr�,-ping rhs 1or7n,l harei+r venffF that the,:ell
(s),ws(nrre)<•onstruned:n arrnrdcax•e%:idr
7.Is this a repair tei an existing well: r Yes or -n o 1S4:VC.C O'C.0100 or 75.4 n`CAC 42C.0200 Tf-eJ7 Conmvcdon Standards and that a com
if rhis is a rrpair.fill rnr",kaohr.well rnnrerucrran irsfc:rrarinn and emlai.-.:hr•nor, F n_I the .10his ircmd has bornprmided ra the rrll o per.
repair under#2l r6md,ks section or on the back ofrfris form.
23.Site diagram or additional well details:
8.For Geoprobe/DP,T or Closed-Loop Geothermal wells laving the same You may use the back of this page to provide additional well construction info
construction.only 1 6W-1 is needed. Indicate TOTAL NUMBER of wcils (add'See O'ee in Remarks Box).You may also attach additional pages if necessary-.
drilled: f
! 24.SUB:YIITTAL TNSTRUCTiON>
9.Total well.depth below land surface: I[J" (ft.)
For•multiple wells fist di depilu ifrhffsreor(crumple-3,gL700"ant/2@,lo0) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of rasing:40 (ft) 24a- For All Wells: Original form to Division of Water Resources (DW'R),
y hater level fs above cesing.wy-+' Information Processing Unit,1617 MSC.Raleigh-NC 27699-1617
11.Borehole diameter 6118 (�) 24b.For Injection Wells:Cony to DWR Underground Injection Control(IOC)
Air Rotary
Progratrt,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: D ary
24c.For Water Supply and Open-Loop Geothermal.Return Weiss:Copy to the
(i.e.sugar,rotary.cabie.'direct push,etc.) county environmental health department of the county whore in.,•talled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over i00,000 GPD:Copy to D\1'R,CCPCL'A
13a.Yield m Cr: Air Lift Permit Program,1611 MSC,Raleigh,VIC 27699-1611
(gP 1 � Method of ft,,,,
Air
Amount: 1/2Lbs
Form GW-( Norh Carolina fhparrmcnt of5n,irom=ral Quality-Division of Ware Ramdccs Rcvis d 6-6-20IX