GW1-2022-09853_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1) For L*rtemal Use Gnly-
I.WeR Contractor Information:
Alfred Kiesling Sr
Well Courracror Namr FROM TO DES(IM 70N
26 70-A ft-
JC
NC Weileil Contract ft ft.
Or Cemfieation Dumber -.
:i;rY (E`FEi2': N ". r 4 iFaeI15:':Fj$:1 '•:.::_.. :::: >.;sr;:,::::.:..
B & K Well Drilling inc FROM I To . D!A'YlElER THICItNE$S MATERIAL
Company Name 0 ft ft- 61/4 in SDZ1 PVC
2.Well Construction Permit R: I rRont ' -
I TO D(A�1E-rER THICKNESS MATERIAL Lk;all applicable well rotcsrrucGon prr•rnrtS;.<.C"IC.(-orarrr.Scott.D-arfancc.etc.) I ft. i ft-
3.Well Use(check weU use): ft_ I ft. im
I
2oGe
er Supply Well: ::
I TO I DIAMETER I SLOTSIIE THICKNFSS MATERIAL
OMunicipal/Public ft. fL in.
othermal(HearipgiCooling Supply) +�dential Wata•Supply(single)
Cr. R in.
uspiaUConuuercial OResidential Water Supply(shared) :.
Olrrigation ❑Wells>100,000 GPD FRUDf ro ritr>arnlipl nc �t MEraoD&.
Nun-Water Supply Well: 1�mirvT
f` 20 ft Bentonite Pour
❑A•4onitoring ORccotcry
Injection WeIL ft- ft-
�AquiferRecharge CGroundwaterRemediation ft ft.
❑Agtufer Storage and Recovery OSalinity Barrier 4f&f
FROM TU !•L�TERIAI- EMPLACEDIEN'T METHOD
CAquifa Test OStamwater Drainace ft fr_
❑Experit meal Technology OSubsidence Control rt ft-
❑Gewhermal(Closed Loop) OTracer
'anti'a�3te�c's: a€sece2�a:'E�??:�"'E:=:::i;�::::?EEiz?i:;;:;;:�:.:
❑Geothermal(HearinJCooling Return) OOther(explain under#21 Remarks) FROM To a>~scRtPrto�(rotor wryroek arm,yrq��)
© ft ft. �LI
4.Date Wel!(s)Completed Z Well IDk ft. ft. yl
h C/ . l/
5a.Well Location:
.n, II Y 4'7Y1,e 1 0 fr.
rhTy/pivTer Name t Facility M)-(ifzpplicable; ft. fL
;l 7 lift-r 6 a �V. - ' ft. I fr-
Physical Address,City.and Zip
/ ft. ft v C LL
Pa �'i1�RE>'�(RIi�:F3: ii:::;::'�3i.:-i%'i%:::Y?:;4`:;r:: :iir.Y:yt?r;:,tfi^:irk•-:i;;,•3'i::;r:2'?-i.s.�>.::::-:::
raj r� ...� .
County rxi Idcntiffcarion No.(PIN) t 4','d�%3 i.
5b.Latitude and 1049itude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,ore:latflong is suoEcient) �.
'22_Certific lion:
ti_Ware)the svel!(s): rJPermauent or OTemporary 5 ofC"i5e.W Cotrsecor Dare
3rr.',gninS this tbtm.l hrrri+r rerriF=firer ter+:rll(sl++Qs(nrrrJ<-onsrrrraed:n acmrdmme:.irh
7.Is this a repair to an existing weU: CYes or _*JNo i5.�:�Co.0 D'C.OTOo cr iSa NGIC??C.OZOo ll'en7 Comavaivn Standards and that¢c�rrt•1f rhir it a repair-fill our knonr well rnnrtrUctian info,a;inn and prnlair the na;rrF n/fire of this mcnrd bes brenprmided to A,+:r/i os acr.
repair undo•:21 r=a,-kt section or on the back ofrTrts form.
33_Site diagram or additional well details:
8.For Geoprobe/DPI or Closed-Loop Geotherma!Wells navina the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicatc TOTAL NTUMBER ofwelis (�'�O-•ee in Remarks Box).You may also attach additional es ifnec
drilled: l P� �S•
/ 24.SUBM- ri'TAL INSTRUCTIONS
9.Total well depth below land surface:_ ( )
For mu/riple nr!!s lzrr df(depi/s ifdrJferent(�rnmp(,et-3(c_00'(Intl J(d IpO� Sub"(this GW-1 within 30 days of well completion per the following:
10.Static water level below top ofeassing•40 (ft 242. For Ail Wells: Original form to Division of Water Resources (DWR).
[f outer(ecel is dbore casing.re,-r-+'• ) Information Processing Unit,1617 MSC.Ralei--I-NIC 27699-1617
II.Borehole diameter.6 1/8 (�) 24b.For Injection Wells:Cony to DWR_Underground Injection Control(IUC)
12.Well construction method.
Air Rotary Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger rotary.cable,direct pashr etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
county environmentalhealth department of the co lmry where installed
FOR WATER SUPPLY WELLS ONLY:
24&For Water Wells producing over 100.000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) � ?Method of test Air Lift Permit Pmgrasr,1611 A fSC.Ralargh.tiC 27699 1611
13b.Disinfeeaon type: Chlor. Tabs Amount 1 1/2 Lbs
I
Form GW-1 North Carolina D�Tznmcnt ofEn.iroamcnral Qualiry-Division of Ware_-Resourccs
Revised 6•6-201 x