GW1-2021-06519_Well Construction - GW1_20210809

aX �2
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Alfred Kiesling Sr
il41TATE&ZONES;:>: ,,. ,>
yy FROM To
DESCRiPTTO\
Well Contractor Name �y^^ �ft. �/Jft.
2670-A �n ft. ft.
r � 00
NC\yellContractnrCenificationNumber ` CtC' v�� r15.;(41#'tEli. ASi1N ftiliSsE(tt�sedlvei75.:DR1EN!✓#t able
B & K Well Drillin IncV. � arC-e FROM TO DI/XytETER THICKNESS MATERL4L
g p ft. ft 61/4 '° SDR-21 PVC
Company Name ^3`�.�
! J7� FROM l0 DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: OOO ((( ft ft
List all applicable well construction peranits,t.e.U1C•.Comm.State. Variance.etc.)
in.
3.Well Use(check well use):
%i17 SCREW
Water Supply Well: FROhI TO DIAMETER CLOT SIZE THICKNESS �I.>TERIAI.
❑Agricultural ❑Municipal/Public ff. ft. in.
❑Geothermal(Heating/Cooling Supply) M<e'sidential Water Supply(single) rt. ft in.
❑lndustna Conne n ial
❑Resrdanhal Water Supply(shared)
::`IS.L3t+i)Q'1'
❑Irrigation ❑Wells> 100,000GPD FROM TU MATERIAL EntPLACF-MENTNIETHOD&.01OUNT
Nun-Water Supply Well: 0 tt' 20 ft- Bentonite Pour
❑Monitoring ❑Rmovcry fr. ft.
Injection W.
❑Aquifer Recharge ❑(iroundwater Remediation
::19:SkNVGiUV. L;:t'�CiG.(If.`� hcebleY
❑Aquifer Storage grid Recovery []Salinity Barrier FROM TO NIATERIAL FMPI-.4CEINENT METHOD
❑Aquifer Test ❑Stormwater Drainaee
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2i�1t7<[3(•1 #U 'attacNa; iiwriirlsheclsiF++ecessirry:;; .:'.'
FR !st TO DES RI (color.hardness.sb" k e. in size etc.I
❑Geothermal(,Heatina/Cooling Return) ❑Other(explain under#21 Remarks) tr. ft.
4.Date Well(s)Completed: Well[D# 06,a. a. p�r�,
a. rt. +0 G
5a.Well Location:
OC � t Pdl. ft. ft.
Facility/ -nerNat Facility II);(ifapplicable) -
I ft.
q
R 6 I t r al
Physical Address.City.and Zip
t;+
D I� q 3: :..
ir�.�l i l 1 _f !� / 23.RE34#AR 5.......
Parecl Identification No.(PIN) t}}
County � J
on
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j�IO
(ifwcll field,one lal/long k wfficicnt) 22.Certification:
N W
11 nata of Certified Well Contractor
6.Is(are)the well(s): OPermanent or ❑Temporary
ate
Br signin„tllic fmm.1 here(!r i•ertifi'that the t+rll(s)+sac(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or �No 15A.NCAC 02C.0100 or IS.a NCAC 02C.0200 11'ell Construction Standards and that a Co1ny
ff rhic is a repair.,frl/nut know n well conctna.-inn rgfannalinn and explain the nature of the gfthis record has been pror'ided to the me/1 owner.
repair ender#21 remarks section or on the back of this forn' 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 construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary
construction only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells .
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11(14 � (ft') Submit this GW-1 within 30 days of well completion per the following:
For ntuhiple wells list all depilu ifdffferent(evample.-3(a000'and 2@100)
24a. For All Wells: Original form to Division of Water R(sources (DW'R),
00.Stage water level below top of casing:40 (R.) Information Processing Unit,1617 MSC.Raleish.NC 27699-1617
1f triter level is above casing,use-
6 1/8 24b.For Injection WeDs: RL Copy to DW Underground Injection Control(IUC)
tl.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:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpnt) Method of test:
Air Lift Pen-nit Program,1611 MSC,Raleigh.NC 2 7699-1 6 1 I
•
13b.Disinfection type Chlor. Tabs 1 1/2 Lbs
4niount
Form(iW-i North Carolina Department of En%ironinemal Quality-Division of Warer Resources Revised 6-6-2019