GW1-2021-01638_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr RCw ®
141E(:4TEiLZ41`1ES
FROM TO DESCRIPTION
Well Contractor Name 3a 11ft.
2670-A P�1 AR X 9 2021 rt, V rt.
NC Well Contractor Certification Number �armation processing Unit lS:E)IiTER:CA51lYG formuttke tiveHs RiI ENER f'` lieable
B & K Well Drilling Iris p�R Sec4ion FROM TO DL1wETF.R THICKNESS I MATERL>L
0 ft• C[a f`• 61/4 in. SDR-21 PVC
Company Name
�V G 16:;fil,ER.G MNG 0RTUBING ea[}lerfiak closed rod
2.Well Construction Permit# 6 t7 FROM ro 1 DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(.e.UIC,C'ormrv.State.Variance.etc.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17$CRt liPi
PPY FROM I TO DIAMETER SLOT SIZE THICKNESS M1t.>TERIAL
❑Agricultural ❑Municipal/Public ft. rt. in•
❑Geothermal(Heating/Cooling Supply) I!Ksidential Water Supply(single) ft. rt. in.
❑lndustrial/Conuuercial ❑Residential Water Supply(shared)
El Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&,OIOUNT
Non-Water Supply Well: 0 t` 20 ft- Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAV#l1GRAV`J[,YACK(if ' lic9tile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MF.THon
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ZI3:13RiLUNG:kOG attaeKadtlttienti1;'sl(edsll:nece3s
FROM TO DESCRIPTION mlar.hardness, iVry k p e Min sae,etc.t
El Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) (9 ft. 0/) ) fi- // r 0
4.Date Well(s)Completed=? _1L Well ID# go ft• '0 rt.
Sa.Well Location: ft. ft. A 19(10
A(t r L M4 '�J [l ft. Cc ft. Ali i✓Id �TJ/ a
�f ft. O fL f
Facility/Oaner•Name
^/ {1 0 Facility�hDy1;(if applicable)
133,3 3 6r-ice.1C of V , 14 W tJ � ft. ft.
ft. ft.
Physical Address.City,and Zip
ee J 46 *715-fpT1IV3 23 72EMARTi5 .s:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/lono is sufficient) 22.Certification: /
N W
6.1s(are)the well(s): ('Permanent or ❑Temporary Signs ofCenified Well Contracto Date
Br si,;ning this.lbrm.1 herehr cerq{ :that the well(s)was(werei constructed in accordance with
7.is this a repair to an existing well: ❑Yes or %o 13A:NCtC 02C.07011 or li.a NCAC 02C.0200 Yell Construction Standards and that a copy
lfthis is a repair.ill oat known well construction information and explain the nature of the gftliis record has been provided to the aril owner.
repair under#2h remarks section or on the back ofthis fn,"i.
23.Site diagram or additional well details:
8.For Geoprobe/DLrT 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 1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d�'iC (ft.) Submit this GW-1 within 30 days of well completion per the following:
Far andtiple hells list all depilts if di_fferent(rxainple.-3(ai200'and 2(4!1001
24a. For All Wells: Original form to Division of Water Resources,(DWR),
10.Static water level below top of casing:4 0 (ft•) Information Processing Unit,1617 MSC.Raleigh-NC 27699-1617
[f muter leer/is shove casing.use••+..
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply 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 mtalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,00'GPD:Copy to DWR,CCPCUA
Air Lift Perini[Program,1611 MSC,Raletgh.NC27699-1611
13a.Yield(gpnl)�� Method of test: 11,,
13b.Disinfection type: ChIOr. Tabs Amount: 1 1/2 LUs
Form GW-1 North Carolina Department of Enoironmcntal Quality-Division of Water Resources Revised 6-6-201 R