GW1-2022-00143_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-11 For Internal use only-
1.Well Contractor Information: I
Alfred Kiesling Sr
Well Contactor Name FROM TO D C:RI'P7T0\ •.
I ...t' ixs..� F� fL
2670-A t b`<rr »I �i; II° �^
qqb IL,.
NC.wall Contractor CertificationNumbzr Ut� FF�`E':�4'iN�:"e>r� ca�edsi�;Og:�tCIf� .''':'':: .g'::?;::>•:::;.::;?'r::E
B & K Well Drilling inc -l•F'(� 1 � 20CL FROM TO DtkME >R TMCKINE MATERIAL
'^ %"'�'n^ f!ri3i� ft. I y �t 61/4 tD SDR-21
Company Name PVC
�{$r4Lr J V�
2.Well Construction Permit# 3 7 1 Y FROM '0 DIAMETER THICKNESS MATERIAL
n r ` i ft. fL in.
Liar all applicable well c'otrsmlrtiar pcnnits,..c'.1./C",C.OfafLY,State.7'ar.'anc'c',lac.
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3.Well Use(check well use): ft. EL in
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::,::::::::::a
Water Supply Well: . .....:.:>.:::...,..:..........::.:<.,....:,.:.,:,...,..... ....;.,.:.,..,.:.....:.......: .'•;
FItODt TO DlAMET&R SLOT SIZE THICKNESS MATERIAL
❑Age culttua! ❑Municipal/Public ft. fL ia;
❑Geothermal(HeatilwiCooliing Supply) ide»tial Water Supply(single)
fL fL iR'
❑IndustriaUConuuercial ❑Residential Water Supply(shared)
:>It.:t711ti1t3t::»::>::;::::::;:>::::<::; ::;.::;;: r :s:: .>.:>::::s::>::;::::: ::•:s:;>;:_
....,.:........... :... :. .,:.,............. ..........: ..:.: :.::.:
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL E*1?LACLNM-TMETHOD&AM0UNT
Nun-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑Monitoring ❑Rccovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation fL ft.?..•, .
:::1?I:�S:�`� r?rL::Pe>lf3f�6f:>;_:.;>. kF?Ei?^::'•.rfaE:i`:>;? ?<:6:E<::?>%:::<'<.i�>???:;��:i#;;'.;?•>?%;Si%%;
❑Aquifer Storage and Recovery ❑Saliniry Barrio I FROM To I MATERIAL. EMPLACEMENT METHOD
C2Aquifer Test ❑Stormwater Drainage fL ft-
❑Experimental Technology ❑Subsidence Control tL ft.
❑Geothermal(Closed Loop) ❑Tracer _....:..... _.:. _.
"2tt�%t3fiilhitV'� �'aFiara'airii£ :3F: 1€>::r: :�`?z:::;^<�:::c:s:; ::i•:::>:>
❑Geothermal(Heatin(Cooling Retum) ❑OthCr(explain under#21 RernarLq) FROM TO DE.SL'RrMOX(color.b2rdness so r k -rant site.«u
�J f4 ft. C
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4.Date Well 4!s)Completedn ' d 2—Wen ID# A15fr. MJ'zr-ffl
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5a-Wen Location: ft. R. fL ''/�,�1/ X�
(b�of irYL11n a m j
Facili /Ow-rerNamt -- -- ft. fL
/ty e' Facility TT)>'(ifxgpilicable)/
It. � fL
Physical Address,City,and Zip ft, fL
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s✓7 q 4 a �.ii'i2';;:^.i;:�; ;:?2;;:;<:.': Sir:;;isii'fi'ii.':i5i+�:?i%`:C:+:�„" S�t;:::::•::i:ic:?>zFi.55•>:
County Parcel Iderdificatioo No.(PIN)
5b.Latitude and longitude in den ees/minates/secouds or decimal degrees:
(if-ell field,one Iattlong is sufficient) 7Z Gertin lien: C ,
N W ` A�
,/'
6.is(are)the weil(s): OPermanent or ❑Temporary 1;.et ofcenined weiTconActor Date (%
4rsigningo this lbnn.l hereby rernf,that the:�e111s1 i• (rvereJ<'onstrucred in acrardmu•e uirlr
7.Is this a repair to an existing well: ❑Yes or nNo J s{:vCa.0 o2C.010n or/i.4 nrCae o2e.0200 tt-en Construction standards and that a cop.%•
IJ"this is a repair•fill out knonr well eanstrtection info,maiinn and explain,the namrr al the of rhis mend has hmir pr'm'ided to the nr11 owner,
repair raider 421 remarks section or on the back of8ris form.
33: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 needed. indicate TOTAL NUMBER ofwciis (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled t 24.SUBMMAL INSTRUCTIONS
9.Total well.depth below land surface: (ft)
For mulrfple itzlls list all depiln ifdiffinenr(erample-3(a,_00'trnd 2@100) Submit this GW-1 within 30 days of well completion per the following:
10•Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information processingUnit,1617 MSC,RaleialL NC 27699-1617
1 f h re ater level is dbore casing, ,'e"+-
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11.Borehole diameter•_6 118 (�) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Prog'am,1636 MSC,Raleigh,NC 27699-1636
13.Well constrDction method:Air Rotary � I
24c.For Water Supply and Open-Loop Geother rnal Return Wells:Copy to the
(i.e.auger..rotary.cable.direct pu h,ztc.) county emironmetital health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY:
2Sd For tiVater Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) :1 J. Method of test:
Air Lift Pcrmtt ProUr m,1611 MSC,Raleigh.iVC 27699 1611
13b.Disinfection type: Chlor. Tabs 4mount �2 �}S
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Form GW-1 North Carolina Drpanmcnt of Ens iroamcnal Quality-Division of Water Resources Rcviscd 6-6-201 R