GW1-2022-09881_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(UW-1) For Lntemal Use Only-
1.Well Contractor Information:
Alfred Kiesling Sr
FROM To DESC ZYMON'
Well Contractor Name ft. �� ft. �r
2670-A �_
NC Well Contractor Certification Number �L t D
:...
:>L-i'�:UFxTEiZ;�3Si>yl•�i ec�tt;�•'ca9e[Isiifi:'�$�1�RE3t � 7:. _: s�:.::..`
B & K Well Drilling Inc FROM TO DL6-NIETER I THICKNESS I KATERLIL
0 ft- I(off ft 6 1/4 in- SDR-21 JPVC
Company frame
d
n�S 7 FROM '1'0 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit m: �
Lisr all applicable wv11 construction permits F,.c.WC.Cotuay.State.Variance:etc.) ft- ! ft 1Q•
3.Well Use(check well use): ft. ft. is
Water Supply Well:
_SG32�&itiFit>'E%i::%i::i:i ??f:'�z:::'.E::.: _
:..-%TE:. . . .
FROltI TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultum! ❑MunicipaUPublic: ft,
fL in"
❑Geothermal(Heatin;Cooling Supply) a<dentia!Water Supply(single) ft. ft- in-
❑lndustrial/Commercial ❑Residential Water Supply 1 (shared)
X.S.
><>
❑Irrigation 0 Wells>i00,000 GPD FROM 2) K1TERML DJPLAC99 tE'rHUD&.•LIIOUNT
Non-Water Supply Well: 0 fL 20 fr- Bentonite Pour
❑Monitoring ❑Ru ovcry ft- ft_
Injection Well:
it. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:c1:4::&4h`$1G1�Y�L:::i'.rYfllr•!� le}::::`��:1:%z:�::??��:�>:F�Alii?�?'?:<?�::::.??�:?ii:%��:i::::
OAquifer Storage and Recovery OSahniry Barrier FROM TO ML>TERIAL EMPLA.CE111ENT METHOD
❑Aquifer Test OStormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft- ft.
❑Geothermal(Closed Loop) ❑Tracer :7RIEi�it4Gf OC`aiFactia ,lieritrFerris z_:;>:::>:<= >>s><:;s>: :
FROM TO DESCRIPTION(color hardness ilfroek gout aiz4 ere.)
❑Geothermal(HeatinJCooiiag Return) ❑Other(explain under#21 Remaris) D ft. 0 ft. X A
4"Date Well(s)Completed- 02 Well ID# 10
tt. fo LG 0 v LLD
We11 Location: ft. ft.I
ft. ft.
t et
Facility"/Owner Name Facility iTY(ifapplicable; ft. n 6 J w 9 is f
- ft. f
ft.
t
P •teal Address,City.and Zip ft. ft.
:.
A
County Parcel Identification No.(PIN) i'QL'S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifw•cll field,one lat/long is sufcicnt) ZVIZ
n:
N W
6.Ware)the well(s): rJPermanent or ❑Temporary Sim a1u. fCerified Well ontmcto , Date
Br signing the fonn.!herein'rertffr7ha1 rh['.:pll(sl eras(were)t•onsrrutred in accordmze-e tridt
7.Is this a repair to an existing well: E.-Yes or !nNo 15d:VCJ.0 02C.0100 or 15.4 NCAC 02C.0100 m en Construction Standards and that a cent-
Lj rhis is a repair"fill our knonz well constntction infor maimn and ernlair the nature n1 rhr njthis record has bernprorided to the+.rl/of aer.
repair raider:21 rema,-ks section or on the back ojrhis fora+.
" 23-Site diagram or additional well details-
S.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-I is needed" Indicate TOTAL NUMBER of wells (add'See Ozer'iu Remarks Box).You may also attach additional pages ifneeessaty.
domed" 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (/� UL) Submit this GW-1 within 30 days,of well corn letion r the following:
For multiple ter//s list all deptla if tkffereni(example-3(m_00'and 2@ 00) P g-
10.Static water level below top of casing:40 24a. For all Wells: Original form to Division of Water Resources (DWR),
(ft.)L%getter level is uhvr"e casing,ure"'+" Information Processing Unit,1617 MSC,Raleigh-ATC 27699-1617
11.Borehole diameter-6 1/8 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
Air Rota
13.Well construction method: 24c.For%Vater Supply and OpewLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable•direct push,etc.) county esrtironmenW health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gplu) (P
/�— Method of test-Air Lift Permit Program.1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount- 1 1/2 Lbs
Form GW-1 Norrh Carolina Department of En,ironmental Quality-Division of Water Raaaccc Revised 6-6-201 R