GW1-2021-01506_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-I For Internal Use Only:
1.Well Contractor Information:
AlfredKiesling Sr , :s= > <::>::<.:.:::.:.:::::::;>>:::..:>:::>::.;::::.;>:;>;::•::;:::.:::::.:> ::.>:.: _::::;::.::.:.>:,:.>.
FROM TO Dggc RrPTiO'.%"
Well Coimactor Name I - t 0 ft -S �
2670-A
NC Well Contractor Certification Number
, :;nRat�PEtX"
B & K Well Dnllin Inc FROM TO DIAMETER THICKNESS MATERIAL
9 0 ft- S ft- 61/4 in- SDR-21 PVC
Company Name
2.Well Construction Permit# FROM TO DIAMrrER THICKNESS MATERIAL
in-
List all applicable well construction permits r.e.L11C,Comae.Srate.Variance-etc'.)
ft. ft. in.
3-Well Use(check well use): _.. ............,.... ......... ......:.......::-:::;.::•::::::,: ;;:,.I.>::;; >
Water Supply Well .:.:.::...:;
PPY : FROM TO DIAMETER SLOTSME I THICKNESS 'MATERIAL
/Agricultural OMunicipaUPublic ft. (L in.
OGeothermal(Heating/Cooling Supply) Mesidentia)Water Supply(single) g. ,fL i1L
OlndustnalrConnterctal ORsfdenri alWatt r Supply(shared) <•''i�-t�[>l3'F<::::>:.::;::>::::;:;':::»>;:z<:>:t,�::«� :z::>:;;�::.;<::;.<:.::«;;::;;:::�;-�<;::>:<:::::»:,;:;::;:;::;:::r:;::;:::<:•::;.;>:.;Obligation 0Wells>100,000 GPD FROM TO ht\TERIAL EDIPLACE?4EN7 AfETHUD6.iNtOUN7
b
Nun-Water Supply Well: 0 CL 20 fr- Bentonite Pour
OD4onitoring ❑Recovery
Injection Well: ft. ft.
OAq uifer Recharge oGrouudwater Reniediation
<;;i3':S+Y�'8>'GS3>r"1L1'r+YFd!S;i�• fable)'::::.:,:::..: .:::.......:,..:::. ....:::.........................
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO 11tATF,RiAI. FMPL.ACDIFNT MFTHOD
❑Aquifer Test OStormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer :Z@?Dlzi3NtE# 'attactratienas3fcatx3:::::?:<::::`:>:::::_'<:`:<'»?<;i;;:;>':•;z.
FROM TO DESCRIPTfO*,(—Ior.hwrdn a W—k .,v,sae ere.t
❑Geothermal(HeatkalCoolins Return) ❑i Other(explain under 1.921 Remarks) fL % e ft. d
4.Date Well(s)Completed`- 3 a'! Well I))# _. G S ft. L 0 ft.
ft. fL f C t
5a.Well Location: L'
� ) ft. tt.
V K I �)� ✓ 1� LI.L.
Facility/OwrerName Facilitym4(ifapplicable) ft. __.. ft.- .
..1
7 6 'mil� •r%� �. G.l� �� fr. � ... ,-
Physical Address,City, nd Zip fr.
County Parcel Identification No.(PIN) ^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification: Y
N
Signature ofCeniHed Well Contractor Dare
6.ts(are)thewell(s): dPermaneat or ❑Temporan-
Br signing this bnn.1 hereby rer ri i;that the :ell(s)leas(tverf)construcred in accordance with
7.Is this-a repair to an existing well: OYes or o 15.4.VCAC 02C.010n or 1".2 TvCiC 02C.0200 Mdl Coaatvction Standards and that a cops•
q'this is a repair.ill out kno%n well construction informal inn and plain the norure raj the q(rhis rfcnrd has Lrcn proridfd to the.Ell owner.
repair wader 421 remarks section or on the back ofdris form. 23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well cons
miction info
construction.only I GW-1 is needed. fndicatc TOTAL NUMBER of wells (add'See Over'iu Remarks Bo.x).You may also attach additional page;_if necessary.
drilled: 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+cells list all depiles ifdiffmni(crumple-3CaI%00'and 2(d).100)
24a. For All Wells: Original form to Division of Water Resourt:es (DWR),
10.Static water level below top of casing:40 (ft•) Information Processing Unit,1617 MSC.RaleigL,NC 27699-1617
fjuvter level u•abuc•e easing,use"+"
6 1/8 24b.For Injection Wells:Copy to DWR_Underground Injection:Control(IUC)
11.Borehole diameter: (in.) Prom-am,1636 MSC,Raleigh,NC 27699-1636
Air Rota
12.Well construction method. � 24c.For Water Snpp1V and Open-Loop Geothermal Return Wells:Copy to the
(i.e-auFzr,rotary.cable.direct push,etc.) county entironIIienral health department of the county where rtLtitalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DW'R',CCPCUA
13a Yield(gpm) � Method etllod of test:
Air Lift Permit Program,1611 MSC,Ralergh.MC•27699-1 61 1
13b.Disinfection type:Chlor. Tabs Amount 1 1/2 Lbs
Form GW-1 North Carolina Department of Encvonmental Quality-Division of Waxer Resources Rcviscd 6-6-2019