GW1-2022-09873_Well Construction - GW1_20221028

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Cootractor Information:
Alfred Kl r'esl'm
g S FROM TO DE.CCRTPITO'.%'
Well Contractor Name If o , /L
ft. o ft.
2670-A s-o iL fL t 1n o,LE l
NC Well Contractor Certification Number =v
s•L-,::UFITER:E�N�:` ei��cssed :;� ��NE�f�tlf::.:•..' '�':'`.i,'^: :: ';:(r;:E
B & K Well Drilling Inc FROM TO DLLNIETER T11100M MATERIAL
0 ft- I�,s/fl- 6 1/4 in- SDR 21 PVC
Company Name
� 7 (� ::;t&
2.Well Construction Permit'I:: a•7 7 -1 �_ FRONT 'I'O 1 DIA-MI TER THICKNESS I:MATERIAL '
Llsr all applicable well rututsucGos permits,r.r.UIC.t.olQnY.Smtr.T'arimrcc.rrrl f[. i iL
in.
3.Well Use(check well use): ft. ft- is
${3�F.8iKi'i:;,::>:::i::i'i:'�i�: ''::.�G>?ti:i: •%c;: iS<::;:i3i::• ..f''?%;Sj� :f::."i�i si'i:i:'>:::;...
Water Supply Well:
FROM I TO DIAMETER SLOT:?i SJZE__J THICKNESS MATERIAL
❑A,@ icultural ❑1vlunicipal/Public ft. ft. is
❑Geothermal(HeatingiCooling Supply) a<dential Water Supply(single) ft. tt_ pe
❑lndusirial/Conm)ercial ❑Residential Water Supply(shared)
❑Irrigation ❑Well,>100,000GPD FROM TO XXTERIAL ENn'LACENIL,TMECHUD&A:NIOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑11•fonitoring ❑Recovery fL I ft_
Injection Well
fL fL
❑Aquifer Recharge ❑Groundwater Re-mediation : ::......>:,•:„> ;<.:.:::>::;;::.:.:.:.:;:.:..::•:•;;,,,..:::.::•:•:;::.;•s.:::::
r1�::5:51\`BIGf�3Y�l�Y(f�4'� cable}•::;:%�::%::z:::=:�=:;;:f:i`:::%;2;::;<.'::::::::�::':::.;•::<:.;;.:.;.5:::?:.:
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO MATERIAL F.MPLLCEMENT METHOD
❑Aquifer Test ❑StormwaterDrainaee fL ft-
❑Experimental Technology ❑Subsidence Control IL ft.
❑Geothermal(Closed Loop) ❑Tracer >2 'r�RL}:L'3iPsv;EC
❑Geothermal(HeatinJCooling Return) ❑Other(explain under#21 Remarks) FRO To DEscRIPTro�tookr.hardness II/rack ?tmr sire ere!
ft. ` ft. 6. J C 1
4.Date Well(s)CompletW:-4 �Wel1ID## �ft. ft. hrr!l-
5a.Well Location: f' / . 5,0
Facilittyy/Ow-nerWarne Facility iTY(ifapplicable) ft. fL
ft ft. RE c 5. r`P
Ph •iceI Address,City,w d Zip ft. ft-
X.
fjlaJcr ,. 3.7- :aE:>isi .......... -
counly . Parcel Identification No.(PLN) 9L1'Fi-.UwG+i LLJ }i/:i j t'ty^�
rAa t ^
56.Latitude and longitude in degreeslminateslseconds or decimal degrees: ti
(if well field,one Wilong is sufcicno 22 Certitic "vn: C
N W � �1i
6.ls(are)the well(s): nFermanent or ❑Tempomrc' Sir-+ar ofCenieedWellContractor Date
Br signing lks)butt.l hereht•rerr(%r char the.:r/1( uas 0—re)ronsrr ucrrd in arcurdarme r:ir/r
7.Is this a repair to an existing well• GYes or nNo 15.4.Cl.0 02C.010r or 15.4 1<CAC n2C.0200 Mee Construction Standards and that a corn
L1'rh(s it a repair,fill our knoMr.well ronsirraaimr infor marinn and erplai',the nQrvri,n1 rhL, n(this r rend has beenprm•ided to rho*r(/onder.
repair rider 421 remarks seeoon or on the back o(this 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 additionaJ well construction info
construction.only i GW-1 is nccdod. Indicate TOTAL!\'UMBER ofwells (add'See Ovee in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
�t _ 24.SiJBR'IIT'I'AL 11�iSTRL`CTTOPiS
9.Total well depth below land surface: a,
(ft.)
Fur'multiple ur(/s fist aft depi/rs if&ffe•renr(�rntnplet.-i(4'_00'ant(3(af 001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to ofcasina•40 242• For All Wells: Original form to Division of Water Resources (D15'R),
p '" (it.)
L%nxrter(errl is above casing,we"+" Information Processing Unit;1617 MSC.Raleigh.ATC 27699-1617
11.Borehole diameter-6 118 (�) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 '
12.Wen construction method:Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Welts:Copy to the;
(i.e.auger,rotary.cable,direct push,etc.)
county environmental health department of the county where installed
FOR WATER SLTPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-16 1 1
13b.Disinfection type: Chlor, Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Dcpanmcnt of Environaramal Qualiry-Division of Water Resources Revised 6-(,-201X
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