GW1-2021-00962_Well Construction - GW1_20210404

I J �� /z7
WELL CONSTRUCTION RECQRD(GW-13 For Internal Use Only:
1.Well Contractor Information:
Alfred Kieslin9 Sr .14.
S.A. � ...................... _ :.......... ...
DEFC.RCPTIO\
Well Contractor NameFROM TOft. 1 C1, C<. /"•
2670-A t�
iL
NC Well Contractor Certification Number
:::1�:':Y?F.�'�: 1•tG'#`oeYa'�hraa:4ef.. ':D�3.,En1F;li' a61e•` i'::.
B & K Well Drilling Inc FROM TO DIA-METER THICKNESS IMATERL.AL
0 ft. S ft.
Company Name 6 1/4 14 SDR 21 PVC
.,
137\ 4:2fw:iTIVI�IrR:.�f��(#R':�'E�>�G''NetliexffiaI3¢Ctised- '"} ::
-�3 7 2.Well Construction Permit#• FROM I 7'O I DIAMETER I THICKNESS I MA'1'lRIAL
List all appl7eable welt coy szructiarr permits r.c.LUK:Cototxv.State.Variance.etc.) ft. I fL I in,
3.Well Use(check well use): ft_ Ct. in.
is>+i:' r:i:?>:i2?? it:i»i ri:...........'::.<,:
Water Supply Well: _.......:..:...:..:..:............:...:,,.:. :::.::.,:..,:...::,.:::::....:.:..::.;::::::::::,.:...:
FROM I TO DIAMETER f SLOTSIZE I THICKNIWs MATERIAL
❑Agricultural (3Municipal/Public ft. fL in.
DGcothermal fHeating/Cooliug Supply) Residential Water Supply(single) lit- ft in-
❑Industrial!Conmtercial ❑Residential Water Supply(shared) :::::::.:::: ::::::
o. »::..:;;;.,:;•>:.:<:;::;:
FROM TO NL-kTERIAL, EDLPLACEMEA METHOM 0t1NT
❑lrcioation ❑W'ells>100,000GPD D&A_
Nun-Water Supply Well: 0 ft. 20 ft. Befitorlite Pour
OMonitoring, ORccovcry
Injection Well: _
C ft_
❑Aquifer Recharge DCirouudwater Remadiation
I9:fi4fi '61ZdV✓L:13a�� £rf I.. ;+::%::::;.v: .
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONt TO MATERIAL I EMPI_ACF.NIF,NT METHOD
❑Aquifer Test DStormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft_ ft.
❑ got etTna](Closed Loop) ❑Tracer 2A:?BJhT151�rL�t7G:sftae#rai#tls"tieata� 36bec�csaraFiC:".:><;'<);?::!=::.`•,r:.;::::;'_.'>;.:`.::;
•FROM TO D&RCRIPTION(color,hardness,soiltwk e. in site.etc.
❑Gegtbemrai tHeatinetCaolinQ Return) t❑Other(explain under#21 Remarks)
4.Date Weil(s)Completed--10 l Well ID# 1&S ft. s ft. -
ft. ft.
�Sya.�Well Location: l .,•,fir` r -
t ft. ft.
Facility/Owner Name Faci1'ty rl)T(ifapplicable) ft. ft. - t� ,}s
11; CA ft. ft ,
Physical Address,City,and Zip ft• fr
'R 1�S#+iit'It
6&sAo .-
Countv Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesfmiuuteslseconds or decimal degrees: DVIR LQ--IIOiI
(ifwall field,one latllong is sutlicicnt) 22.Certification:
N V4 / � !/1��t5f49e
6.Is(are)the well(s): dPermanent or ❑Temporary It t9tature Certified Well Conuactcr � Date
B•signin,,o this•iorm.I hereby cert;fi that the i>rll(si ivas(ivere)consirnrred ih accordance»ire:
7-Is this a_repair to an existing well: D Yes or No I sa vCaC 02C.010n ar 13.4 VCAC 02C.n20n!fell Comoruction Standards nd rivet a Coln,
tf rh&s a repair.•fell our kno>v well consinicrion infor maiinn and explain tke nature of the ofthis record has hrca provided to the.:r11 osmer.
repair larder#21 remarks section or on the back gfAus form. 23.Site diagram or additional well details:
8.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.only WW-1 is needed, Indicate TOTAL NUMBER of-wells (add'See over'in Remarks Boy:).You may also attach additional pages if necessary.
drilled: 6 , 24_SUBMITTAL INTR SUCTIONS
9.Total well depth below land surface. ��^� (ft.)
For multiple netts lyre all depth•iftlfff'erent(eaample-3(a)200 and 2@10(y) Submit this GW-1 within 30 days of well completion per the following:
0 (ft.) 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing:4
lf,roter lewt is•above cnitng.eve +" Information Processing Unit,1617 MSC.Ralo(gr,NC 27699-1617
11.Borehole diameter:6 1/8 24b.For Injection Wells:Copy to DWI,Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ail- 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 tr stailed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells proclucing over 100,000 GPD:Copy to DWR',CCPCUA
13a Yield(gptn) Method of test:Ai r Lift Permit Program,1611 MSC.Raleigh.NC 27699-1611
. Tabs
13b.Disinfection type: C'h�Or. TBbS Amount- I2 LbS
r
j
Form G W-1 North Carolina Department of En%ironmcmal Quality-Division of Waer Resources Revised 6-6-201 A