GW1-2021-05712_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr GJE NJ
FROM TO DELCRIP7fO\
Well Contractor Name
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NC Well ContractorCeriticatitnr Number 6 (4 wel�}:(llt:lalHfff if'' lieable
B & K Well Drilling irtt�IC7t34ni5eeon FROB TO ER THICIiiESS MA7ERt�L
Inc
ft. 1a• SDR 21 PVC
Company Name 76::!NIVERCfSIPI t)R:2[TB t; 'eetbeifita}`ciiisedTteB 3
2,Well Construction Permit#" \ �� � FROM I 'r4 I DIAMETER I THICKNESS I MATERIAL
Lisr all applicable well construction permits x.UK,,Cocain.Stare.Variance.err.) tt. ft. in.
ft.
3.Well Use(check well use): ft. in.
Water Supply Well: FROM TO I DIAMETER I CLOT SIZE THICKNESS M 4T£RIAL
CAgricultural OMunicipal/Public ft. ft. in.
OGcothennal(Iicatin9/Cooling Supply) Vesidential Water Supply(single) ft. ft in:
Clndtstnai.Cotutertral ORstdenhal Water Supply(shared) <Otrriaation OWells> 100,000GPD FROM I To K%TERLAL FNIpLACEMEI�TRfET'xoD.&.1:\iOUNT
Non-Water Supply Well: 0 r` 20 r` Bentonite Pour
C'Monitoring ❑Rccorcry i't. €t.
Injection Well: rt. ft.
OAquifer Recharge 06rouadwater Remediation
1t}SA1lSGit :YE #'fifiC€-bf fife
❑Aquifer Storage and Recovery OSahi iry Barrier FR01M I To_ MATERIAI, EMPL.4CENIFM MF. OD
❑Aquifer Test OStormwater Drainage
❑Experimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer Z1I31Rlfl,LhiG'fOGatta�karfthtwtisils etssfsetessarrl
FROM I TO DESCRIPTION Ieol r•hnrdnesss tUroek erarr sizes ere.l
OGeothermal(.HeatinglCooling Retum) OOther(explain under#21 Remart:.c) ft ft.
4.Oate Well(s)Completed:L �'� Well ID#
ft. qk ft.
Sa.Well Location:
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Faeility:ounerName FacilitvflM(ifapplicable) _
fr. it.
it. fL
Physical Address,City,and Zip
County Par'cCI Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i if u el l ticld,one tatt9ona is sufficient} 22 Certitl Dn:
N w
gnature of Cenitie(.well Contra or Date
6.ts(are)the well(s): ''�Pertnanent or OTemporary'
Br signing this firm.)her eAr ce,t hj that the 11(5)was(uerr)ronstruc,red in ac:ordance with
7.is this a repair to an existing well C.ryes or 1 A NCW 02C.0100 ar 7S.4 NGIC 02C A200 M-ell CoRstmctian Standards and that a tol!r
lfrhir is a repair.fil out knot+n well cnnstntcrion informoi on and lain rhr narure of the of rhir record has becn prorided rn h5,'r.r/l ocanm.
repair raider#21 remarks section or on Ike hack ofdris farm. 23-She diagram or additional well details
S.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 i GW-1 is nccded. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: A 24.SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface: � � (ft') Submit this GW-1 within 30 days of well completion per the folio*wing:
For multiple.%ells list all deprks ifdifferent(.::ample-A(CO0'and-'4!100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft•) Information Processing unit,1617 MSC,Raleigh.NC 27699-1617
!f ruder level is abu+'e crsirig use"+" i
6 1/8 24b.For Infection Wells:Copy to DWR,Underground Iniection C ontrol(ItiC)
LI.Borehole diameter- ( J Pro ram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
Air Rotary 24c.For Water Supply and opi n-LoopGeothermal Return Wells:Copy to the
(i.e.auger,rotary,cable•direct push.etc.) county enyironmenW health department of the county where in,,talle('
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodu nm,over 100.000 GPD:Copy to DWR,CCPCUA
., Air Lift Permit Program,1611IvISC-Ralcigh.Ai ?7H99-1611
13a.Yield(gpm) Method of test:
13b-Disinfection type: Chlor. Tabs Amount: 1 112 fibs
Form Gw-I Forth Carolina Depanincnt of En,iroomental Quality-Division of w'arcr Rcsnuiccs Rc.viscd 6-6-201x
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