GW1-2021-01639_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: RECLG NEE
Alfred Kiesling Sr ,4.a�°� R ► � ,.
R 2021 FRONT TO DESCRIPTION
Well Contractor Name I+Art -L D n. 60 ft. tb P
2670-A If` unit ft ��� ft. s��y� -A�-/ "kr,
Processing
NCW""ellCrnttractorCertificatirntNumber
�ri�`vrrl1e�tlOn ii.-R-FASLNGlarmttidreasadarelkDlritNFsft heabie
pWR Section FROM TO DIAMETER THIC6NESS MATERL4L
B & K Well Drilling Inc 0 ft, 6 1/4 in' SDR-21 PVC
Company Name .If Ii!1b1ER itiSI1R1G()R [FB1�TG eot3iermat elased l }>:
2.Well Construction Permit#:9� �Q- 00 4'r( FROM ft. to
TO D14MEI'EK THICKNESS MAFERL4L
Llvt all applicable well construction permits fix..UK'.County.State.Va ianCe.erc.j
ft. I ft. in.
3.Well Use(check well use):
17;:SCRESIY ik ,. .. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) 121Eesidential Water Supply(single) ft. ft. in.
Olndustrial!Conunercial ❑Residential Water Supply(shared) &
❑Irrigation ❑Wells>100,000GPD FROM TO MAATERIAL ` ElI LACEMENT METHOD&"IUUNA
Nun-Water Supply Well: 0 tt• 20 ft- Befltonite Pour
❑Monitoring ORc occry. ft. ft_
Injection Well: fe. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i�::Ss11V9�GR:Y�t.I'kL•1�6f,, lrcible) <s ;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO hIATF,RIAL FMP1..4CFa1F,NT MFTHOD
❑Aquifer Test
OStormwater Drainage it. ft
❑Experimental Technology OSubsidence Control �}ft ft
OGeothermal(Closed Loop) OTracel i0:13I/t1#[t#VG'LOG:attach atldlitiviia�sSedsSlnetessa;v..' .
FROM TO DESCRIP ON color.hardnast.soiVro k r.Ve.grain size,etc.I
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) a, Q ft. / 0
4.Date Well(s)Completed 4 L Well ID# tt. ft. ��QWI� A►`' t�/
a•
Sa.Well Location: 1 11 0 07
Facility/Owner Name Facility M#(ifapplicable) Q ft. 4 ft. r
es
V�/1�0 ��Yl t•Y`r v L� �dn rr� wot ft. fr.
Physical Address,City,.and Zip
.....;....._._:
xF:RF3VLARK5:
eZd flc3 S -
Countv Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifwcll field,one ladlong is sufficient) 22.Certific tion• l
Sigoat ofCenitied ell Contractor Date .
6.Is(are)the well(s): Oermanent or ❑Temporary..
Br signing this form.!herel!r eerrifi that the�:rU(sl was(tvereJ eonsnuered in nee»rdant•a n'irh
or 2K. 15A NCAC 02C.010n or 75.4 NCAC 02C.n200 Well Co+utruction Standards•and n_ that a coi
7.is this a repair to an existing well: ❑Yes
!(this is a repair.fill our known well eansirm. +injnnnatinn and explain the nature nJ the
orthis retard has been providrd to the v.rll ownrr.
repair under 421 remarks section or on the back 0.011is form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See❑vet'in Remarks Box).You may also attach additional pagcs:if necessary.
construction only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
r
9.Total well depth below land surface: tJ 1 (ft') Submit this GW-1 within 30 days of well completion per the following:
For andriple+cells lisr all depilu if dii(ferent(trample-3(a)300'and 2@J00)
40 24a. For All Wells: Original fort to Division of Water Resources (DW'R),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC.Raleigh,NC 27699-1617
/(ruler level is abuve cashig.use"+'•
6 1/8 24b.For Infection Wells:Copy to DWfL Underground Injection C'onrrol(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 en�•ironmental health department of the county where to taped
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin>7 over 100,000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1611
13a.Yield(gpm) Method of test:
136.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Revised 6-6-201R
Form GW-i North Carolina Department of En%ironmental Quality-Division of Waicr Resources