GW1-2022-09882_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-.
1.Well Contractor Information:
Alfred Kiesling Sr
Well COlnrdetOT Name FROAI To DE.VC:RIPTIO\
2670-A M( `` 0A,6
0011. ft.
NC Well Contractor Certification Number J
ii:iLOFs�`•FEiZ:�i�$NUf'
B & K Well Drilling Inc FROM TO ----- IER THICI:1vE5S MaTEizLAL
Company Name fl ft- ft- 6 1/4 in- SDR-21 JPVC .
2.Well Construction Permitm:_ FROM •ro utaMErER THICxnass ..•••MATE RLaL
Live all applicable well colsr acaon prrn±ru .c•.U7C'.Co,orrv.Susie.T%arancc•.etc•.j ft- fL in-
3.Well Use(check well use): ft_ ft_ in_
Water Supplv Well: <'r[73Sl3iffivCfi;<`:;;s:::;:':<:` r:<' :><'7;:<:>>:>;::<::::<::::;;:.;>.;::>:: ';as<:.1::>::;::.a;s>•a::;::::<. ..,::
FftOAi TO DIAMETER SLOTSIZ6 Tlllllt MATERIAL
OAgricultutal ❑MunicipaljPublic ft. fL is
OGeotherm.al(HeatinsZjC.00liiug Supply) 2<deirtial Water Supply(single)
ft_ tL is
❑Industrial!Comnrercial ❑Residential Water Supply(shared)
.:::...
::;:::•:i:<;:<»:sz::;:z::>::;i.•:.::
❑)rrigation ❑Well,-"A 000 GPD FROM TO MATERIAL ENIPLACEIEA'TMLTHOD&AAI6tM
Non-Water Supply Well: Q fL 20 fL lBentonite Pour
❑A•lonitoring ❑Rcr:ovcry
Injection Welk
❑A uiferReebar`e ❑Groundwater Remediation
ft-
❑Aquifer ft.
Storage and Recovery ❑SalinirvBama
FROM TO MATERIAL EMPL4CEMFM METHOD'
❑Aquifer Test ❑Stormw•aterDramaee ft. ft.
❑Expenmental Technology ❑Subsidence Control ft_ ft.
❑Geothermal(Closed Loop) ❑Tracer
2�:PAil E3i�TGMOO?,
DGeothermal(11mi m(Coolke Return) ❑Other(explain under#21 Remarks) FROM To I DESCRIPTION'(color.mra rock rype.sea n silt ere)
ft. ft_
4.Date Well(s)Completed /7 •Z WellID#1 (t. 2 ft. 10
5a-Well Location: ft. ft. r tT,s c� Ain•
ft. ft. a a. ,+i 5 V .ri
FacilitylO nerName : F
acility M�(ifappFcable, ft• fr. n r
ft.
—real Address_City,and Zip ft. fL rib:
:r2i iTtE3liifiR'S:<:?:: ::::(:::d?'':>:.:;:':#<::?::::<r:>'::::'::;:::::<::::F:i::::;•;;r.;:.,.:;.:<:.:.r::::<::::::.s<.e:>:::;:
County .Pwrcl Identification No.(P1N)
5b.Latitude and lonotude in de.-rees/minutesiseconds or decimal degrees-
(if-ell ticld,one lat/long is sufficient) 22 Cc do .
N W
6.Ware)theweli(s): nPermanent or ❑Temporary Sig= ofCertilie Covnz.or Date
Brsignin�11.,L form.1 hereby r"fr that the+.rll(s)ivas(sere)constructed in accordance::itlr
7.Is this a repair to an existing we1L• UYes or !nNo PS4.Vc4c 02C.0700 or 75.4 NC.IC 02C.0200 Ttell Colavverion Standards and that a corre
q"rhis v a repair.fill out knonr well construction info;malirm and etnlair.the nature nj the of this record hat 6 en pror ded to the xrll ouacr.
repair rorder t21 remarkv section or on the back of rills 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-1 is necdcd. Indicatc TOTAL NTUMBER of wells (add'See Over'in Remark,Box).You may also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Z7J (fL)
Fur multiple 1 tc11s lit all depiln•ifdtffet-en r(example-3(a200'an711(d11001 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 All Wells: Original form to Division of Water Resources (DWR),
lfi,"Wer level is abor a casing,we + Information Processing Unit,1617 MSC,Raleigh NC 27699-1617
11_Borehole diameter:6 1/8 }(-) 24b.For Iniection Wells:Copy to DWR-Underground Injection Control(IUQ
Air Rota Pro_sratr4 1636 MSC,Raleigh,NC 27699-1636
i.e Well construction cable. method.. Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct putih,etc.)
county environmental health departarent of the county what in,talled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
(gP ) Method
13a.Yield m Q 4� _
of test:Air Lift permit Program,1611 MSC,Raleigh_ivC 27699-1 6 1 1
13b_Disinfection type: CIIIOr. Tabs amount 1 1/2 Lbs
I
I
Form GW-f North Carolina Dcpanmcnt of Ens ironmcmal Quality-Division of Ware Resources Rcvised 6-6-2019