GW1-2022-09863_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1)
For lntemal Use E�nly:
L Well Coutractor Information:
Alfred Kiesling Sr
Weil Con X.
rrac[or Name t•RODI TO
2670-A f( fo t DrccRlrnO,
m � �
NC Well Contractor Certification*lumber fr. /r rqVV
:>L . :.Leek,LNE3?-B & K Well Drilling Inc FROM TO DULNICTER T�,(��> rE
nAL
Company Name 0 ft. I 7 ft. 6 1/4 1°• SDR-21 PVC
2.Well Construction Permit=: FROM I TO uLU1V'rER Urr all applicable wall consm-rCtion penn11T,•.a UIC.(-omrnt Suue.Yar.'oncc.etc.) ft. ft. in" THICKNESS I Ma7FR1:LL
3.Well Use(check well use): ft. I fr. in
Water Supply Well: - 1
FROM _..TO ..
O.Agricultural DMunicipaUPublic DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal(HeatingiCOolina Supply) ft• it iIL
PP Y) �dential Wat;�"SuPPIY(Single)
ft. fL in.
OResidential Water Supply(Shared)
Dlrrigat i
on DWells>lU0,Q0UGPD FROAt To
Non-Water Supply Well: MVZERf� E�iPLAC ffNT MEtHUD&AMOUNT
it 20 f`- Bentonite Pour
❑Ii4onitorinr ORcco(-c
Injection Well: ry ft. fr.
OAquiferRecharge ClGroundwaterRemediation ft. fr_
1 •':S_SAiGRii Y :::4ui er Storage and Recovery OSalinity Barrier �f;�Y2'�4iEt�:,:-:':,:iibleT:•:::i;%::;;>is'E5�<:
..:FR(711 TO ALATERIAI. EMPLALCEI(IENTMETHOD...:
CAquifer Test DStormwater Drainage ft. ft.
GExperimental Technology OSubsidence Control tc
it_
❑Geoth ermal(Closed Loop) DTtacer :;: ..: .. .
I3NG f f?C'sFaicti'a�iLYi, 7 $F.oeces ss IiasEi;%Y?i:7>::# 'i%?r<tt>si•;;:;E;:1::;'i
❑Cieothettnal(Heating/Cooling Return) ❑Other(explain under=21 Remarks) FRoat To DE.SCRIPITON tea, nara,tr� rack n,..^r 4 Ncl
�( fr. ( ft �i L
4.Date Wells)Completed-t/ tat Z e11 ID# �`'tt. ft,
Sa_Well Location:
50,
l O
Fa6lrty/Ow-ner Name
�y n Facility m�(if/zpplicaabble,, fr• fc
ft. fL
Physical Address.City,and Zrp ft- fr- 1
County .. ..c.e. Pr , r.+^�s:�:j- '•.:.
Parcel Identification No.(PIN) Uni;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifu,oll field one latflong is sufficient)
2-2-Certification:
�. _2 -C�f�
6.is(are)the well(s): 01'erruanent or ❑Temporarc• Si ar ofCcrtified Well Consactor Date
7.Is this a repair to an existing well- Dyes Or Bl•signins-this la m•I hereln..rerrift:rnat the nP11(sl vas(IVere)construcied in arcordanc•e wi1/r
1N0 15.-1:YCIC 02C.070r or I5.4 XCAC 03C.0200 tr'rl CoiLowctfon standards and that a cant•
IJ'rhis i.T a repair.fill nu;knoxz well c»n.Ttrtrcaiar lnforrnafion and emlair rho narvrr of the of this rrcnrd has bcra prat-fded to the er/l of 7tvr
repair under Q1 remarks sectJar or on the back orr)tis 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 i GW-1 is nccdcd. indicate TOTAL INFUMBER ofwciis (add See Ovee iu Remarks Box).You may also attach additional pages ifnecessary.
drilled:_
24.SUBMITTAL TNS'[72UCTTONS
9.Total well depth below land snrfaca: Ot-K� (�)
Fa mulriple nrf/s list 1111 depilLy ifckJjerrnt(�nmple-S(ar_ )'nnr(?(dt/p0� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
Lf inter level is chore easing,r.-e"+"' (ft.) Information Processing Unit,1617 MSC.Raleigh_NC 27699-1617
11.Borehole diameter:6 V8 (in) 24b.For Iniection Wells:Cony to DWR_Underground Injection Control(IUC)
12_Well construction method:
Air Rotary Program,,1636 MSC,Raleigh,NC 27699-1636
Re.auger,rotary-cable.direct push"etc") 24c.For Water Supply aad Open-Loop Geothermal Return Wells-Copy to the;
county emironmental health department 71 the county where in.,-talled
FOR WATER SUPPLY WELLS ONLY:
of �( 24d.For Water Weds prodncina over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) _Q�� Method of test Ali Lift i L pRT°tt>'*o��*r.1611 I�SSC.Ralegh.NC 27699-161 I
13b.Disinfection type: Chior. Tabs Amount 1 1/2 Lbs
i
Form GW-f Nonb Carolina DrTanmcnt of Ent-iroamenral Quality-Division of Water Rc_,.ovrecs
RCv15cd 6-6-20 i R