GW1-2022-09855_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1} For L*rtenal Use Only.
L Well Contractor Information.
Alfred Kiesling Sr =
Well Coutrattor Nam: FROM TO DE..
2670-A ff. jft. _1_1n11G
L ��
NC Wcll Contractor Certification Number fL
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B & K Well Drilling Inc FROm TD DlAwrer tt IHICICNES$ MATERLA.L
Company Name 0 ft- fL 6 114 SDR--21 PVC
2.Well Construction Permit I [-ROn[ TO utaME-n:R TRtCKT M17A7ERIaL
iis:all appl:cabld well ranstnlcGar prrnrts .e.L11C'.Coro,SU7 te.7"an.'ontet etc.) ^I CL tL im>
3.Well]Use(check well use): R- fL ecPP_ e11. in.
Vat Supply Well: Stith'Fa!t::;_ :;::;::':x:;::_<:.>::<�;::i;;�::>'?:::: ,:':i7z:<t>: : :;:"�F':i;?E>:::>: ??:<s::•::..:
FROM TO I DIAMETER SLOT SIZE THICKNESS !MATERIAL❑Agricultural ❑Municipal/Public Ct. ft in
❑Geotheral(Reating%Cooling Supply) idential Wat;:I•Supply(single)
ft. fL in.
❑lndusuiallConunerciai ❑Residential Water Supply(shared)
❑lrrigation ❑Wells> 100,000GPD Fxvu To ,.,.x+rsrtTAT.: : Enipinc nrMsraoDa.lvOUNT
Non-Water Supply Well: O fL 20 fL Bentonite Pour
❑Monitoring ❑Rccovcry fr. fr.
Injection Re1L
❑A uifer Recharge ❑CroundwaYer ft fL
Re-mediation
0 uifer Story aik'S iG83Y 1 3'4f ...........RItife .::; ::>c;t ;MPLA`EMEN r'+.q Storage and Recovery ❑Salnttty Barrier } ..................:..........:...::•::::.:�::..
FRC711 7U t•LaTERU[. EMPLACEMENT MEfHUD
GAquifer Test ❑Stormwater Dramaee It. it.
❑Experitt enrol Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ,:..,...:::,.:.:...
��`PAFlhil��;£•Oti:�tt��ha�tee :use«essrkJ:�>:r:?::::::?:>:E-�ti;;<:: <::;<:;.;:<:rr::::
UGeothetmal(lieatiaJCooling Return) ❑0th�(explain under#21 Relnarl�c) FR
nt To DESQtIPIYO\(carat hardness, ruck ,;ice m
ft. 0'r_©f
4.Date WeTl(s),Cotapleted: l=Z-3vell ID# ` ft. ft
Sa.Well Location: IL ft `f a r. /
C/
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_� his Oft. %
Facility/Owner Name ••" Facilityln;(ifml;cable, ft. fL
Physical Address.City.and Zip R f, OCT Q
t :'-ZItfi(Rlr''::iii'issE'': %z'iif::::<"::;; ii::::::i:`;;<:::u:::;;:K?:::.;,< •:::_,;:
.. . .....:.:..::....:...
County Pa.:cl IdeatiEcation No.(PIN)
5b.Latitude and longitude in decrees/minatesiseconds or decimal degrees:
(ifw•en field,or Ixtl7ong is sufficient)
22_Certificati n: �
/
6.Ware)the well(s): r Permanent or ❑Temporarc• S;9=ure Ceriti Well onaactor D
Ersignin�rhs%orm.1 hereht•rc rrr(-r=that tar+:tilts/+.as(Icrm)<-orrsrruned in arm daure+rirh
7.Is this a repair to an existing well;- GYes or .-1No 15.E:VC.JC 02C.070n or 75.4 nC14C,92C.11200 McMCorrtmucaon standards and that a can,•
1%rhis is a repair fill our knoe+r well c»nrnta7iou igforrnarinn and E rnlair rha namre n1-rnr a(this reemd has lien prm ided m the.rll o.aer
repair rnrd2r r11 rema*s seccon or on the back ofrhis Earn+-
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-1 is nccdod. indicaic TOTAL NUMBER of veils (add'See Over'in Remarks Bo-).You may also attach additional pages ifnecessary.
drMed: '
}p� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,7 t��J
Fur mulrfple nips list rtlf dePiky iMfferenr(-cwnple �-3( 00'anti j 0 11 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of using:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
!j niter 1e+r1 is dbgre casing.zwe"+•• Information Processing Unit,1617 MSC.Raleish.NC 27699-1617
11.Borehole diameter:6 1/8 (iy) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
12.Well construction method: C�
Air Rotary Program,1636 MSC,Raleiggh,NC 2 7699-1636
(i.e.auger..rotary.cable.direct push:etc.) 24c.For Water Sapp tw and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county ahem installed
FOR WATER SUPPLY WELLS o.NLY:
24d.For Water Wells producing over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Vr Method Df test.A�ir Lift permit Program,1611 MSC.Raleigh.NC 27699-16 1 1
13b.Disinfection ty m
pe: Chlor, Tabs Aoun l
t. 1 f/2 Lbs
Form GW-f North Carolina Dcpatrmcnt of Environmewal sell Q ry-Division of w'azc Rao+acec Revised Erfi-?OI✓t