GW1-2021-02256_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
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FROM TO DINC.RIPTION,
Well Coutractor Name ft. ft.
2670-A
ft. rt.
NC Well Contactor Certification Number 15ic71i€)2~R1i::Eo1 �1 :(f6cm%fftriiied wells:;E1CYi;ES�1Eit stile`i i'::'>''i>`:'<':>.
B & K Well Drilling Inc lunar TO DLIYIEW THICKNESS MAT€RUL
0 ft ft. 6 1141 SDR 21 PVC
Company Name
} G "Nw '£ZtESll�t%( T�1JBL*TEtxhernbalelaaett .:
2.Well Construction Permit 01 / FROM 'r0 I DIAMETER I TnICKNEss IMaTERIAt
List all applicable Kell construction periniu(i.r.•UTC'.C'oruuc.Srnie.r'ariattca.etc,) ft• I fL I in.
3.Well Use(check well use): rt• ft in.
WaferSupply Well: FROM I TO I DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricuhural OMunicipal/Public ft. ft. in.
OGcotherrital(Heating/Cooling Supply) rdetttial Water Supply(single) ft_ ft in.
Olndustrial!Conunercial Residential Water Supply(shared)
3'31 7L(?13#X
0Irrigation 0W'ells>100,000 GPD PROM I To MATERIAL EMPLACE.M�TMETHOD&.AMOUNT
Non-Water Supply Well; 0 ft. 20 ft. Bentonite Pour
O\'loiitoring ORccovcry ft. ft.
Injection Well:
ft. R.
OAquifer Recharge 0(iroundwater Remediation _.....
OAquifer Storage and Recovery OSaliniry Barrier FROM TO NIATF.RIAI. I EMPLACEMENT MF.TH00
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
OGeotherma3(Closed Loop) OTracer
OGeotberrnal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM To DescRtP v cobr.Waco z goal. :�:size-«G
ft. ft,
4.Date Will(s)Completed d41 Well ID# C ft. R. elp Q ra I
5a.Well Location: ft.
Facility/Otcncr Nam Facility iT)#(if applicable) ft' ft'
�3 > 6 1 S S Il ' 1 0 ft. ft E 1 VE. -
Physical Address.City,a d Zip ft. ft.
...........:.....
County PaiveIldcntification No.(PIN) r,alrapl t'f^Ge551fIS1 nl
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -,Pee,,en
(ifwcll field,one lattlong is sufficient) 22.Certification: .
N 4-7- 2-
6.ls(are)the well(s): dPermanent or OTemparary
Sigrature ertifiec.ll Contractor Date
Br signing this lapa.1 herel v reri h that the:rl!(s)nts(were)constructed in ut:nrdonre with,
7.is this a repair to an existing well; OYes or 01 sA VCAC 02C,410n or 15.4 NCAC,01C.o100 Well Cowtmchot Standards,tad tliat a co'my
Jj this is a repair v.l/out knon well vottrinaaion infonnaaNiXd6plainrhenowrea"th" of this record has been provided to the>trd owner.
repair under#21 remar kr section or on the Back ofthisform.
23.Site 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 constr fiction info
construction.only I GW-1 is needod. hidicatc TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional page: if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )4 14 (ft) Submit this GW-1 within 30 days of well completion per the following:
For ondriple hells list all depths if different(example-3(a)_00'and 2@100`
24a. For All Fells: Original'1 form to Division of Water Resoti:;ea (DWR),
10.Static water level below'top of casing:�� (ft.) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
f'curer levet i.r above Casing,use
11.Borehole diameter 6 1/$ (in,} 24b.For Infection Wells:Copy
• to DWR Underground Injection Control(WC))
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air rotary
24c.For Water Supply and Open-Loop.Geothermal Return Well,:Copy to the
(i.e.auger;rotary_cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells DrodncinQ Over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Prag ani,lfil 1 MSC,Raleigh.ltiC 27699 1611
13h_Disinfection type: Chlor. Tabs Amount- 1 1/2 Lbs
Form GW-1 North Carolina Department of Em irotuncnial Quality-Division of Water Resources Ro ised 6-6-2018
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