GW1-2022-09878_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1} For Lntemal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
Well Conrracror Name FROM TO DFSC:RrMO.N ..:.
2670-A ft_ ©If- a(1 �AeFs
NC.Well Contractor Certification Number r
ei„Z6�'.c884ed'$el�:':E)�aa_ {I[':..�:,.. .�..:,';:::;.,i:s•:,i::i
B & K Well Drilling Inc FROM TO DLLv1ETER THrCtiNE58 MArER"L
Company dame 0 ft• �'I A—ft- 6 1/4 in- SDR-21 JPVC
2.Well Construction Permit m:c3 IFROM r0 ulA?7E rER rxtcxnrs5 ntATERLaL
Lirt all applicable well coltit uCGon per:ni4T .e.UIC.Corurre Stare.t%or.'ance.etc.) ft. fL in-
3.Well Use(check well use): ft_ I fc. is
Water SuPP iv Well: >:L7:SG3i_ffi5:......;;:
-
FROM TO OlAMETEFt SLOT SIZE THIC.KNES8 MATERIAL
❑Agricultural ❑Municipal/Public ft• fL in.
OGeothermal(FeatinviCooling Supply) a4idential Water Supply(single) ft. fL ira
01ndusu-ial/Contmercial OResidential Walser Supply(shared)
::iSi:L;:itf113'!':::ii:8 ::;::;::�:�:<::::::;�:;:>::>:i::::.:>:;;;::.:�:::�:.:�:>'�;::::<::>::::-:>:i;>:;:;::•.;>::::::;:::i:::s:.:,�::,;::::;:;::.
Olrrigation O We]ls>100.000 GPD FRUIIr TU 1L�TERiAL E11PI ACE�ETHOD&.A.MOU1
Non-Water Supply Well: O ` 20 fL Bentonite lPour
❑Monitoring ORccavcry
ft- ft-
Injection Well:
OA uifer Recharge fL ft.
9 OGroundwater Ramediation
&41rB GH3Y5 1'4f3S?fif;:;:: %f>::_>::;::«
DAgmfer Szotage and Recovery1 t.................i..............:::::..::::::•:::::..:.::.
DSalllliCy$sine[ KRUM TO hI.4TER1Al, FMPL�CEhIFM METHOD
CAquifer Test OStormwater Drainage fL fL
OExperimLmal Technology OSubsidence Control fL ft.
❑Geothermal(Closed Loop) OTracer
OGeotherrnal(HeatillWCOOliag Return) OOther(explain under#21 Remarks) HROIM TO I DESCRIMO' (rotor_hardness son/reek �2b size-
ft. ft.
4_Date Well(s)Completed:-��i ,�z Well ID# �ft, ft
c/
5a_Well Location: ft. fL
D
Fa rhtylOarerNarne l Facility M"(if applicable, tr- fL
3/7� �O(5 t,�?,j- - ft. 1 fL 2
sical Address,City,and Zip ft. fL
.. _
Q Y. .. :..........:::ii:i i::::..,,y. .i.y:::::.::ni::::. .7Jl IV'4tSY+i:��:i:;l.Y�A�ih�Y nl1
County yit
Pa:cel Identification No.(PIN)
v 1iSC'ti�
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees-
(if-'ell field,one]at/long is sutftcicnt) 22_Crrtificali
6_ls(are)the well(s): IJPermanent or OTemporary S:==ure 9PCerzified well Colmaetor Date
A'•slgning-rhir form.I herebl•cm7f(1:thar rhP+rnll(sl wtrs(were)<•onsirucred in arc ordanve::•ith
7.Is this a repair to an existing well.- Dyes or nNo I5.4:VC%iC 02C.010n or 15.4 ACAC 02C.0200[f ell Construedon Standards and that a core-
lfrhLs is a repair;fill our known well consinaaion informaiinu and e,nla47 the naturr nfrhe of this reenrd har b,er.prorided m the v.rll ow wrr.
repair rarder 421 rema cr section or on the back ofrkis 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 is needed. Indicate TOTAL NUMBER of wells (add'See Ovel in Remarks Box).You may also attach additional pages if necessary-.
drilled: j
7 n 24.SUBMITTAL TNSTRUCTTO-Nlz
9.Total Well.depth below land surface: LJ(/�
dfffe
Fu multiple a rils list aff d if epils re, (,,ampler-3(a'=0 0"ane12 @ 100) ( )
r Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft.) 24a. For 911 Wells: Orig al form to Division of Water Resources (DWR).
Ifwater leer/is ubot•e casing.tar••+'" Information Processing Unit 1617 MSC,Raleigh ATC 27699-1617
11.Borehole diameter:6 1/8 (in_) 24b.For Injection Wells:Copy to DWI_Underground Injection Control(rUC)
Prog-atn,1636 MSC,Raleigh,lvC 27699-1636
12.Well construction method:Ar r Rotary
(i.e.auger..roCary_Ca612-direct pus14 etc.) 24c.For Water Suppiv and Open-Loop Geothermal Return Wells-Couy to the
cotluty arnronmenral health department of the county where in.s lied
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield m Air Lift Permit Prourram.lbIIMSC,Raleigh_1,,iC27699-161t
(gP ) Method of test
13b.Disinfection type: Chlor. Tabs Amount 1 1/2 Lbs
Farm GW-1 North Carolina Dcpanmcnt of En,ironmental Quality-Division of Warcr Rcsou=cs Revised 6-6-2019