GW1-2022-09880_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
L well Contractor Information:
Alfred Kiesling.Sr
::-79;:SS:sY3�1E>zi> is�: ::::>::i:<::<:`z>::>.::;:> _>:.>:::;;:.-:.;>_:>:>�:>::::�>::�::>:::<::: ::::::.:...•:.- .
NeD Contractor Name FEtOpI TO DESCWPTIO\
26 70-A ft. ft.
NC Well Connactor Cerrification Number
�J v ft. ft. /g!� d�/=
B & K Well Drifting inc fqm-
0
FRORI TO DY04ETER THICKNESS MATERL�I.
Company Name fr• fr- 6114• in- SDR-21 PVC
//�� 5' B'GSls?: :': k `.FIBZ•?Fi . aY....;
2.Well Construction Permit#: 3 q-� - ? I FKOAt I TO DIAMbTER THICKN[•SS.....:.--6[ATERIAL
Lit:all applicable xell cotutnsc bar permtlS .e.GIC Lorarrv.State.M2,,"onrc tac.) f[. i fc is
3.Well Use(check well use): ft. I fL in
i
Water Supply Well: ::
❑. t:Ult(Ird1 FROM I TO DLIMETER SLOT SIZE THICKI`FSS MATERIAL
❑vlunicipal/Public is I fc I in
❑Geothermal(Heatin_iCooling Supply) a<dential Water Supply(single)
❑industrial! ft. I ft hL
Conuuercial ❑Residential Water Supply(shared)
❑Welts>100,000 GPD FRUI[I TU M�IERIAL E*IY7 ACET MEIBUD&1�IUtJNI
Hurt-Water Supply 0 tL 20 fL Bentonite Pour
❑Monitoring ❑R=ovcry ir. fc
Injection Well:
❑Aquifer Recharge ❑Groundwater Remadiarion fL ft"
❑Aquifer Stara
G ....g nttyamcr
. .. .........:....... .............
FROaI TO MATEfiIAL EMPL4CFJUEIVTMETHUD
❑AquiferTe,Gt ❑StosmwaterDlaivaee fc fc
❑Experimental Technology ❑Subsidence Control fr_ fc
❑Geothermal(Closed Loop) ❑Tracer
>'2t> i�C h33lTG 4 'a iscf;a to-RWal i£ e :.'•>?:<:E:::[?t£a:>:i: {r;»>r:,:':'
❑Geothermal(Heatia?/Cootins Retum) 00ther(e.�lain under#21 Remarl:_c) FROnt To D><seRlpno�(color_esranemt rode ?rmt ma�t�t
ft eft. J 0 t t
4.Date Well(s)Completed:-4L r `.7_well ID# ft. ft.
Cl
5a.Well Location: 0 ft. ft.
T/ f
4(0 ft, ft. y�fQ f
Facility/OtvTrerNamr ��.'�[ FacilityTl)�(ifzpp!".cable; S fr. fG -�!�
5-
P reel Addre>s.City.and Zip
County Pa._cl ldcndfication No.(PIN)
5b.Latitude and Nonag-itude in degrees/minutesiseconds or decimal degrees: J��art s3O€si�
(if wcll field•om Wong is sul;rcicnt)
22_Certif�ca- n: �
6.Ware)thewell(s): (nPermanent or ❑Temporary S:=zrute fCeriSed WellCo[t¢acor e I
3rsignin,-fmsfotn:.Jhereln rerrff-r;nor me t:rll(s)+vas(were)constnrroed in arcordewee t.irb 7.Is this a repair to an e a wep; C.-Yes or
>a M V O !S.;:VG C 02C.0100 or IS.;lv°C IC m( •OZ00 Ti dl Co crtrvcron Standards and rhar a cute 11'rhls is a repair-fill n«r,biohr.wel(ennrnucngn infornmarinn and eml017 the nature a!'rne ?fthis rand has bcca prmided m the.rll o,mvr.
repair rarder:"21 rV*r,kr secuon or on the back of leis-m.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use[he back of this page to provide additional well construction info
construction only i GW-1 is ncedod. Indicate TOTAL NUMBER of welts (add'See Oven'in Remarks Be--).You may also artach additional pages ifnecessmy.
drilled:- 1
9.To (Pw 24.SUBMITTAL INSTRUCTIONS
tal Well depth below land surface,- (�)
Fur•mukiplr urns list all Japils lftli•(ftTent(centuple-3[ 00'«ad 36a,1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of rasing:40 (ft 24a. For All Wells: Original form to Division of Water Resources (DVVR),
!f Herter level is«bore casing,we.-+•' ) InfOtrtatiOn Processing Unit,1617 MSC,Raleigh-NC 27699-1617
11.Borehole diameter_6 11$ (in-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(rUC)
12.Well constriction method:Air Air Rotary Program 1636 MSC,Raleign.1JC 27699-1636
(i.e.auger.rotary.cable.direct push.,-!Cc•) 21c.For Water Supply and Open-Loop Geothermal Return We%:Copy to the
county env rronmenW health department ofthe county where ii.,'talled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100 M GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Z- Method of test•Air Lift Permit Proms-rn.1611 MSC.Ralagh.tiC 27699-1611
13b.Disinfection type: Chlor. Tabs kmount 1/2 Lbs
Form GW-f North Carolina DLparrmcnr of En.iroamenral Qualiry-Division of Warc-Rcsou ecs
Rcvistd(i-6t 101 i