GW1-2021-06515_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-II
For lntemal Use Only:
1.Wen Contractor Information:
:::>:
Alfred Kiesling Sr ;:;:;::>::;:<:.::.,::.;;:::; :.::..
FROM TO DESCRiPT70N ,{n}
rel
\Nell Contractor Name ft' � t. " ��t/
2670-A
NC Well Contractor Certification Number >R4ONI THIf M•': MATERIAL
FAOM To
B & K Well Drilling Inc 0 fr. ft. 6 1/4 1n- SDR-21 PVC
Company Name 2f;;?Lti1VER0<r1��FSB€7NI eer7texmaF'HI
Q� FROM7 .N
'O UTAE'rER THICKNESS MAT'ER14L.
2.Well Construction Permit#: r ft ft• to
List all applicable well corstrurtiorn permits i.e.UK.Coloay.State.Variance.eta.l ft. in.
ft.
well use).' •::;:;:: .........
3,Well Use(check )
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Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
ft. ft. 1O-
❑Geothermal(Heatin�/Cooling Supply) asidcntial Water Supply(single) {t- ft.
❑Residential Water Supply(shared) MGROUf;>s:s:>.;::>;
❑lndustrial!Conurlercial FRUItI To M4TE121AL EAIPLACEMFI\T METHOD&.\\[OUI rT
❑Irrigation ❑Wells>lUO,OWGPD 0 fL 20 ft
Bentonite Pour
Nun-Water Supply Well:
❑Monitoring
❑R=ovcry
Injection Well: ft ft.
❑<irouudwater Ranadiation ` P4f6f
❑Aquifer Recharge
_4CFntFVY METHOD
❑Saliiiiry Barrier FROM TU AI.4TF.RIAL
❑Aquifer Storage and Recovery ft. ft.
CAquifer Test ❑Stormwater Drainage
Control
fc, ft.
❑Experimental Technology
❑Geothermal(Closed Loop) ❑Tracer nEs, iPn N lcobr,hardness k ¢rain size del
FROM TO
❑Geotbermal(Heating/Cooling Return) ❑Other(e.•tplain under#21 Remarks)
4.Date Well(s)Completed:-7 sZ WelI ID# V
ft. tt.
5a.Well Location:
Faeilitytowner Name Facility M#(if applicable) � a�
ft. it
......... .
,.:
physical Address,City,a,,d Zip
County Parcel identification No.(PW)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if u•cll field,or+c IaL'lono is sufficient.)
22.Certifies
N R
Signature o ertI ell Co tractor Date
6.Ware)the well(s): OPermanent or ❑Temporary
Br signing this 1orm.1 heretic cer-r(h''that the+:rl!(s)uas vrreJ<'onsnvt•ted in are•ordanre pith
1 t•.t.VCAC 01C.0I on or 15.4 NC.AC 01C.n100 five!!Coarruc-lion Standards and that a cops
7.Is this a repair to an existing well. ❑Yes or [nNo ofrhis rrcnrd has been provided to the vr0 of tier.
lf�his is a repair.fill nutkna�n well<nnymartir»n information and explain the nature ey e
repair under 921 remarks section or on the back of this fornr. 23.Site diagram or additional wen 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 Over'in Remarks Box').You may also attach additional pages if necessary.
construction.only I.GW-1 is needed. indicate TOTAL NUMBER of wells 24 SUBMITTAL INSTRUCTIONS
drilled: f — n _
9.Total well depth below land surface: bc-Q —(ft.) Submit this GW-1 within 30 days of well completion per the following:
For muiriple II-ells list all depths if di ferent(Trample-3(an300 ant!3(d!1001
40 24a. For AU Wells: Original form to Division of Water Resources (DVI'R),
10.Static water level below top of casing: (ft') Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
l f uulet-level is above,casing.m'e"+" Underground Injection Control(II)C)
6 1/8 24b.For DWR b Injection Warts:Copy to
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:Coo y to the
(i.e.auger,rotary.cable,direct push,etc.) county enNironmental health department of the county vt°hrre to tallecl.
FOR WATER SUPPLY WELLS ONLY-_ 24d.For Water Wells producin>:over 100.600 GP D:Copy to DWR,CCPCUA
13a.Yield Om) _ Method of test.
Air Lift permit program.161i MSC,Raleigh.NC 27699-1 6 1 1
13b.Disinfection type:
Chlor. Tabs Amount- 1/2 LbS
if Revised 6-6-101 K
North Carolina Department of Ern ironmental Quality-Division of Water Resources
Form G W 1