GW1-2022-09858_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW_D For Intemal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
Well Contractor Name 1 TO DESC:RIP►'10\
2670-A f` DSft• slok'� {� v
!Jf fL fL n NC Well Contractor Certification Number
B & K Well Drilling Inc FROm TO I DULMETER T13100'ESS MATERIAL
Company*lame 0 tt• I��s ft- 6 1/4. In• SDR-21 PVC
2.Well Construction Permit#:_SJ 17 to �p FROM 1 '1'0 DJA E ER TntCKnEsc MATrRtat
Liss all applicable well CGrtSmrfGon permrLs .e•.UIC.Corarn.Susie.I%aancc•.erc•.j ft. I fL M.
3.Well Use(check well use): ft_ fL in-
Water
e Supply Well: . :::::::;,;;»:::::>;.;;:;>...:.
FROM TO DIAMETER ICKN
SLOT srZE THFS$ MATERIAL
OAgricuhura! ❑Municipal/Pliblic ft. fL in.
OGeothemlal(HeatinviCooling Supply) a<dential Water Supply(single)
ft. fL in.
❑lndusiriaKontntercial OResidential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM To MATMA1 E*LPLACEM iT METHOD&11IOr1NT
Noll-Water Supply Well: 0 Cc 20 fc Bentonite Pour
❑;�4onitoritTg ❑Rtxo�'cty
Injection Well: ft_ ft.
❑A uifer Recharge rL fL
q OGrouudwater Ramzdiation
>z3 :$>sz :. .::
❑Aquifer Stores a and Recov GR1 G3'> ?6fTT atikt<`:s::iz:°? ZEME>
b' cry OSalltliry Barrier FROM TO MATERIAI. EMPLACEMFM METHOD,
❑Aquifer Test ❑Stormwater Drainage fL ft-
❑Experimental Technology OSubsidence Control fL fL
❑Geothermal(Closed Loop) OTracer
❑Geothermal(HeatinWCooling Return) OOther(e.tplain under=21 Remark) z Rost TO DESCR3PT[ON(c kr.hardness rocs ?rm size ere l
ft. 0 ft. L�4 f sot
4.Date Well(s)CompletednA 9�`WellID# 10 ft. d ft. t2 �Ol� v
52.Well Location:- rf ft. ft. �T
t"s ft. ft.
Fa rftTy/ChwTrrNarne Fzcility M (ifapplicable,' ft. fL �,'_� ' a. +r
NL>Lil��/ fr• 1 fa
Physical Address,City,and Zip "" [(_ fy
OCT 8
ll 'Y?/D-.19- Ar6 7
Cousin Pa._cl ldenMicarion No.(PW)
5b-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-ell field,one lattlong is sutTrcicnt)
22.Certifica'On:
Y. -- 2
6.ls(are)the well(s): r Permaaent or ❑Temporary .—at ofCenified w Coutractor Date
Brsigning rhs)orm.l hrmF cmrfii:rhar me.:rll(s)isas(iserej ronsrrucied in arcardanve;...w,
7.Is this a repair to an existing well- GYes or 79.-I XCAC 02C.0700 or 75.4 XCAC 02C.0200 lief(Corrtavcrim Standards and rhar a corn•
V'rhis is a impair:fill our knonr.well<»=Inamirni info warinn and erplair the norvrr ill rill, o(rhis mcord has been proiided m the rrl1 owner.
repair imder#21 remarks sector or on the back oJrltis form•
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 1 GW-i i;needed. Indicate TOTAL:NUTMBER of wells (add'See O.•ee iu Remarks Box).You may also attach additional pages if necessary•.
drilled: I
n 24.SUBIIITTAL INSTRUCTIONS
9.Total well depth below land surface:_tad�S
(ft)
Far multiple iirlls list afl depf/rs ifrdffe•rrnt(ernmpl (ct_e-3 00'snit 3(t{!1001 Submit this GW-1 within 30 days Of well completion per the following:
10.Static water level below top ofeasing:40 (ft) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
If wafer Intl is above casing,u e'"+" Information Processing Unit,1617 MSC,Raleigh NC 27699-1617
11.Borehole diameter:6 118 24b.For Injection Wells:Copy to DWIL Underground Injection Control(IUC)
Air Rota Program,1636 MSC,Raleigh,NC 27699-1636
12-Well construction method:Air
(i.e.augzr,rotary,cablz,direct push.etc.) 24c.For Water Snpply and Open-Loop Geothermal Return Wells-Copy to the
county emnronmental health depamnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD Copy to DWR,CCPCUA
13a Yield m Air Lift Permit Pro�mam,1611 MSC Raleigh.NC 27699-1611
(gP ) Method of test
13b.Disinfection type: Chior. Tabs Amount- 1 1/2 Lbs
. I
Form GW-1 Nona Carolina Department of Era iroimmcnral Quality-Division of N'arcr R�­oiacec Revised 6-6-201 R