GW1-2021-00938_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD(GW-1i For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
FROM TO DECC.RrPTION
Well Contractor Name
2670-A t y v/r tt, ^
NC Well a Contractor Cemif+cation Number i V a,
QQ ':13_fdll'E'1AE�i$i+16`.' a�mt04ttutstitl tvel�:EJ1ZLflYBR <; ail' ,
B K Well Drilling Inc FROM TO DLA.o1ETER THICKNESS MATERLAL
p ft, 1 9-5ft. 6 1/4 In SDR 21 PVC
Company Name
�7 J�'Q ::}.&:: EIt't:,1'S1P1Li-(3Zt�:�T1.B�'4x eot#eermafetb�d-
2.Well Construction Permit l+r• � Cl 1 [_J I) FROM I TO DlAmel,ER I THICKNESS I NtA'tERI•tL
Lisr all applicable well construction perinits i.e.VIC,County.Srale.Variance—re.j ft. I in.
3.Well Use(check well use): it. to in.
Water,u i Well:
PP y e FROM TO I DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgriculttual OM icipal/Public ft. ft. in-
OGeothennal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft iR7
Olndustrial/Conui)ercial OResidential Water Supply(shared)
,..
t)I1'f
Olrrigation OWelis>100,000GPD FROM To MILTERUL nIPLACE?rENTMETHOD.&AAfOt)NT
Nun-Water Supply Well: 0 fL 20 ft- Bentonite Pour
❑Monitoring ORcc:ovcry ft. ft.
Injection Well:
ft. fs
OAquifer Recharge O(iroundwater Remediation t
�4::fi41+•DlGtt<i`4�:..P�;�1€faf- . .. bte ... <^. ;<....:::
OAquifer Storage and Recovery OSaliniry Barrier FROM TO MATF,RIAI FMPI.ACENIENT METHOD
❑Aquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTrdcer Dltti T ilsl :l lilt.attaciradd,fturtas cesv ' ...
OGeothermal(lleatinz(Coolina Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTIO\ w1or,hardness.soillrock tot.mein yec eta.
4_Date Well(s)Completed: -7 -�;kl Well ID# r , �,, ?Q
Sa. ell Location:
t(WA A 3 �l <�` r 3psft, So '-
lr G1rS � U 0 SGGt >`d'U,� ft. ft.
Facility/owner Name Facility M#01'applieable) ft. ft.
S b LA 1 1 1� � ��W� 5 c��r� i i fu ft.
Physical Address.City,and Zip ft. ft.
:•2lc:RE1YIXR` ;:..�1 { i; :;::;:z:'.:::�,,..:::�..::::-.:,;.......
C(LAa, �1701Y,Zr'G�,2
County Nxccl Identification No.(PIN) p;:acessin Unit
51b.Latitude and longitude in degrees/minotes/seconds or decimal degrees: nvjgSection
(ifa•cll field,one Iatilong is sufficient) 22.Certification:
6.Is(are)the well(s): ()Permanent or OTemporar} Sigaatf of Cenifiec,Well Contract n Date
_jjJ Br signing this form.!hereFx rerti(i that the+:�77(s/sas(were}ranstracred in ca:,,darn e+vith
7.Is this a repair to an existing well: OYes or 'SJ Y0 15A NCtC 02C.0100 ar ISA ArCAC 02C'.0200 dell Couttruction Standards and that a corm•
�I afthis record has heen rovided ro the.ell owner.
!f this;.r a repair.fill out known well cnnstnrcrrian infonnotinn en P.tplain the aarur•e a)the p
repair trader#21 remarks section or on the back ofdds form.
23.Site diagram or additional well detAs:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pave to provide additional well constuction info
construction.only I GW-1 is needed, Indicate TOTAL NUMBER of wells (add'See Chce in Remarks Box).You may a6o attach additional pagea if necessary.
drilled:._ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For nnt/riple+rells Cut all depths if tfifferent(example-3(q!200'ant(@ 00'1 Submit this GW-r within 30 days of well completion per the following:
10•Static water level kelow top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(1.0 Information Processing Unit,1617 MSC.Raleigh_NC 27699-1617
!(/rater leer/is above casitig.me"+•'
il.Borehole diameter 1/8 (in.) 24b.For IDieetion Wells:Copy to DWR,Underground Injection Control(RUC)
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 die
(i.e.auger,Tocary.cable,direct push,etc.) county enr.ironmental health department of the county inhere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over 100,000 GPD:Copy to DWR,CCPCUA
r�
13a.Yield(gpm) Method of test:AlrLeft Permit Program,1611 MSC,Raleigh,NC 27699-161 1
�✓ {.
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Luis
Form G W-1 North Carolina Department of En,ironarcnral Quality-Division of W'arcr Rcsourtcs R-ised 6-6-201?
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