GW1-2022-09875_Well Construction - GW1_20221028

i
WELL CONSTRUCTION RECORD(GW 1I For lntemal Use Only.
L Wen Contractor Information:
Alfred Kiesling Sr
2;fl?�r is�::ii:;:: :.<:;::i-.;'a'::;,.:;:;$:;:?::2:;:#:: :<:<::::.;.;:# :%;':�<?:�; ::;i::>:::�;::;-:::•::wen Contractor Name FROA TU DESCRtP1T0\
2670-A ft• ft. p,r�/
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J fc ©5-
NC tVdl Contractor Cetrification Number r
B & K Well Drilling inc : gT�aFLPF$` ti'.:::::_:::;:<:::
Company Name rt• I? ft. 61/4 in- SDR21 PVC
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2.Nell Construction Permit s: 9� I Exont I TO DIA-NIMR THICKNEb's MATERIAL
LLSr all opplieable wc11 consrniCGon permtfS l.e•.U1L.Corarty.State.Variance-.dre.) f[. i fe in.
3.Well Use(check well use): ft. I fL is
F
r Supply Well:
ricultural FRONt .. _..To.': DIAMETER: SLOT SIZE THIC.KNF$,C-.•..-.•.MATERIAL
OMunicipal/Puhlic ft. ft is
othermal(FieatinSicoouiig Supply) �dential Water'Supply(single)
llST17a1! fL I fL in-
Conuuerrial OResidential Water Supply(shared)
Olmgatton ❑Welts>1UO,000GPD Fxoi,t To :...,.... ».::.. :,;.,;::.:::...:::...::•::-:..:.,:.;;..;::..:.;::.:..
M:�TCafn7 E�iPI.ACEi4E+,T METHOD&:L1IOU-NT
�lon-Water Supply WdL• 0 fc
20 fc Bentonite Pour
O:ifonitoring ORccovcry
Injection Weil- rr' ft-
OAquifet Recharge OGroundwater Remediation ft ft.
OAquifer Storage and Recov E<:p9S:S iG83k 4E3 ...........Tllite........' ; ;•1:.:: ::3<><>:;:::::a:::'s•^::>'::a<»=»>»»>:�' OSalltttty Barrier ...,... ........:.....:.....:�:._:•:.:.
[_'+•Aquifer Test FRb�i TU MATERIAL. EMPLACEI1tENTMETHOD -
OSLOrmwater DraL7+af'C rL fL
OExperimental Technology OSubsidence Control FL ft
OGeothermal(Closed Loop) OTracer
OGeothermal(HeatiflWCAoling Return) OOther(e'tplain under#21 Remarks) SRo*t To DESCRIYTfO\fo br ttaratress, roar g- * tite etel
fL ! ft.
4.Date Wells)CompletW- ell IDt# j- fL 0 ft.
JSa.Well Location:_ AA 0 fL fL /mom
m�� C t}:�I,l fL ft.
Fa^iliQty/OnrcrNamr Facility i11;(ifapp!icable; 0 ft. �V fL
Wr L 1 1 S— fr ft.
teal Address,City,and Zip ft. fL
7
coum
;.
• Pa_cI Identification No.(PiN) DL +t.Mt 1lN9.,,
5b.Latitude and longitude in degrees/minatesiseconds or decimal degrees:
(ifwcll field,one ladlogZ is surTrcicat)
22.Certificat,
6.is(are)the well(s): OPermanent or OTemporary 4S1- ofC-�,,-,e'd Well Co. or Date
Bp sgninS rhs Jonrr.!herein•rerdfj=that titP+:rll(s/++as(tarp/<•onsrrurred ire prrnrdrun.r::irb
7.Is this a repair to an existing well G Y'es or �N o l U NC.3C 02C.0100 or iS.a 1vCAC 02C.0200 Meg Cortiruccon Sla»dwds and thar a ctmt
11}his iT a repair.fill am kno7.well4—strucrmn informarinn and atplai,,the aaw,,nl'tir ofrhis record has bcra prcrided to the veil owner.
repair nuder>21 texts.kr section or on the back of rhrsform. '
33.Site diagram or additional weft details:
S.For GeopcotH!DPT or Closed-Loop Geothermal Wells havina the saute You may use the back of this page to provide additional well construction info
construction.only i GW-1 is needed. Indicate TOTAL NUMBER ofwclls (add,See ON-&in Remarks Box).You may also attach additional page;ifnecessary'
drilled:_ f
9.Total well depth below laud surface; 24.SUBMnTAL LNSTRUCTIONvo
For•multiple rcells kin all depib-if&fferenr(trample-3(at_0ll and 2(a,!J00� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level belmv top ofcasing:40 {ft. 24a• For All Wells: Ori_cdnal *"orm to Division of Water Resources (DWR);
Lf outer level it above casing.use"+" ) Infomration Processing Unit,1617 MSC.Raleigh.ATC 27699-1617
II.Borehole diameter.6 1A (in.) 24b.For Injection Wells:Copy to DWPL Underground hijection Control(IUC)
13.Well construction method:
Air Rotary Progr=4 1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary.cable•direct pu;tL etc.) 24c.For Water Supgi and Open Loop Geothermal Return Wells-Copy to the
cottuty ent�ronmenral health tiepaznnent of nc�county udr sr intalled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100.000 GPD•Copy to DM-R,CCPCUA
13a Yield(gpm) Method of test.Air Lift Pcrmrt Program,1611 MSC,Raleigh•tiC 27699 i6t 1
13b.Disinfection type: Chlor. Tabs .amount: 1 1/2 LbS
FarmGW-1 Nonh Carolina IDTarrmcntofBn.iroa=ural Quali
ty ry-Division of Warc RL<owzcc Rcvixd b.!-ppl>t