GW1-2021-01513_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Alfred Kieslmg Sr
FROM TO DE¢CRIPTlON'
Well Contractor Name
2670-A t
NC Well Contractor Certification Number . ...
15s:: .EitCiSS1sVG fuifmtt#i tiised :f3R:1tNER aAi
B & K Well Drilling Inc FROM TO DLa-WTER THICKNESS MATER1,41.
0 ft 61/4 in SDR-21 PVC
Company Name
:k�'�9VER?E`•ah5�ii(��'F)BL'�"'ee�term�!";,.,.,
FRON1 1,0 DIAMETYR I THICKNESS MATERIAL
2.Well Construction Permit#
List all applicable well construction pennits,`ix.L11C•.Comity.State.Variance.dw) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
F7:'iSC.31
W er Su i Well: ,:.. .•.... .:..::..:::.::>:,...:::..:.:,:::::::::..:.:...
PPY PKUnI TO DIAMETER $LOT SIZE THICKNESS M11.47EKIAL
Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/C:ooliug Supply) L'lResidential Water Supply(single) ft. fL in.
❑ dustnal!Conuiiercial OResidenhal Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM I To MATERIAL E-LPLACF-MUT AfrMO.*.&.41fOUNT
Nun-Waier Supply well: 0 fL 20 f` Bentonite lPour
❑Monitoring ❑R=ovciy ft- ft.
Injection Well: ft. fr.
❑Aquifer Recharge 06roundwateI Remediation ,.• �.. ,.. ..::. . . r::••::::,<..,:.::::::::::::•:...:::::::::...:.,•.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 75�
l9 f4C:'attaitka�RIPTs els3L:.hedaii so>?;;z:::sz:«:>< <:>:_:_:;;_e;:<>:>:.,:
FROMTO DESC:RIPTFO�(eoMr.hardness so0rroek � arse.ete.1
❑Geothemlal(Heat Return) ❑Other(explain under#21 Remarks) ft. l r
4.Date Well(s)Completed- Well ID# ft. l.JSa.Well Location: XS .. aL
ft. s C
2Facility/OtvnerNajme y� y� y�� 4 y�FacilitvM (ifapplica e) ft. ft.
I l 1 1 1" lC� J/ 1� � ft. ft.
Physical Address.City.and Zip 4L _
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C A Co )2 e,
County Parecl Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i;, y
(ifwcll field,one lat/long is sufficient) 22.Cek%6reai ontii"•fit
N ur L a z0t�
Signature ofCenified Well Contactor Date
6.Is(are)the well(s): dPermanent or ❑Temporary
-
Br signing ifty lar m.l hereby Cerro that the i:rll(s)errs(were)construt red in accordance with
7.is this a repair to an existing well: ❑Yes or o I5A:vcAc 01C.01nn or 15.4 hCaC 02C.0200 if-ell Cantmrction Standaras.pnd chat a eopy
1l rhis;.v a repair.ill out known well constna:tiou iniormaiinn an chin the nature nl the q(this record has been provided to the aril owner.
repair under#21 remarks section or on the back of thisform. 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
(add'See aver'in Remarks Box).You may also attach additional pages
construction-only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells if necessary.
drilled: .1l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface• ` — ^® (ft) Submit this GW-1 within 30 days of well completion per the following:.
For multiple icel/s lisr all depth'if cGfferent(e-vainple-3(a1200'and 2(dt1001
24a. For All Wells: Original form to Division of Water Resources (Dw'R),
10.Static water level below top of casing:40 (ft') Information Processing Unit,1617 MSC.Ralei?b,NC 27699-1617
11 iitrter level is above easing.use"+
(i6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
il.Borehole diameter: n•) Program,1636 MSC.Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water SuppiV and Open-Loop Geothermal Return Wells:Copy to the
(i.e:auger,rotary-cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin>7 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Pr�,ratn,1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 Lbs
Form G W-1 Nonb Carolina Department of Em tonmental Quality-Division of Water Resources Revised 6-6-201 tt