GW1-2022-01876_Well Construction - GW1_20220216

i
WELL CONSTRUCTION RECORD
For lntemal Use Only.
1•Well Contractor Information:
7.
14��° l�n "DEICR[PT[O\
Alfred Kiesling Sr FROM To
t �k-
art. c ,2tq,G �-
Well Contractor Name x.,t,,, .,a -� .-
2670-A _ u 6 L u0 7✓►�F o
FEB 16 20ZZ etl ells 1t:3 tNER' t' e
a U. . Ei2E 5iNG foimtifn v1 THICKNESS MATERUL
NC Well Contractor Ceriification`lumber FROM TO
6 & K Well Drillingrj.M;aZ� ���°Un ft. It- 6 1/4 i°ETER SDR-21 PVC
26:::itVN1 R`G' G(RiTE[L N eoibertnaistesed
Company Vame /�-rf �j DIAMETER THICKNESS MATERIAL
f L' FROM '1'O
2.Well Construction Permit#: t
-� ft,
List all applicable well construction pcnnia(i.e.U1C..Cotutrv.State.hnnanee. ft• ft. in.
3.Well Use(check well use): t.7c:SCR1 Ef? MATERIAL
AL
TO DIAMETER SLOT SIZE THI(:KhES$
Water Supplv Well: ft ft. in-
❑Agricultural ❑Nlunicipal/Public
_/ ft. in.
❑Geothermal(HeatimdCooling supply) rsida,t,al Water Supply(single) ft
❑IndnstriaUConuvrrcial ❑Residential Water Supply(Shared) f8i.4IIUIIT
FROM TO MILiER1AL E*fPLAGEVt1*7 ME[HUD&.O(UUNT
❑Irrioa[ion ❑Wells>100,000GPD 0 f� 20 fL genfonite Pour
Nun-Water Supply'Well: ft. ft.
❑Ndonitoring ❑Rmovcry ft.
Injection Well: ft.
❑(irouudwater Retnediation le'
tt. ft
❑A<1Ulfei Recharge FROM TO M>TERIAI FMPI>CEMENT MFTH(In
❑Aquifer Storage and Recovery ❑Salinity Barrier
19sS4N9lGRaV�1.Y:4GK f�f,.
❑Aquifer Test ❑Stolmwater Drainage
❑Experimental Technology ❑Subsidence Control
ft ft.
❑Tracer i9DS1£Ll;.. aiipcha al.sLeed3fnecessarv;
❑Geothermal(Closed Loop) FROM To DESC IPTIO\(color.hardness soJ rock cram sru eref
❑Geothermal(HeatinJCooliag Return) ❑Other(explain under#21 Remarks)
ft ft. p
Z Well TD#
4.Date Well(s)Completed: 1 ft. 0 ft. r
li
a-Well Location: f<. fr.
ft. ft-
FacilityMD (ifappNcable)
/D al 170� t l��f ft.
lap ft
Physical Address.City.and Zip ��
DrJain � 7'�
Parcel Idantification No.(PLN)
County
r,
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees: �2 Ccrtificati In: /
(ifwcll field,orw lattlono is sufficient) 24� P�
W ef/
Si�nat Cenitied Well Conaaaor
Date
6.Is(are)the well(s): dPermanent or ❑Temporan
Br natursi�nitArfC Illis Joan.I he Well
k.cetrih`that the�:rll(sl wnc(were),rnsuvcted in acmrdal-e with
1 t,.l:VCAC 1)2C.010n or 15.4 ACAC 42L.n2po If Ca2rt1-LlCtlott SlandaRlS and that a tJtrP
7.Is this a repair to an existing well: ❑Yes or nNo of thk rrcnrd has been pre ided to the rrll or .nrr.
If rhis is a repair.fit/out kno%-n well<anstna-tian infonnorinn and explain the nature nfrhe � Site diagram or additional well details'
repair tender 421 remarks section or on the hack of this farm.
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 1 GW-1 is needed. indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled: I
9.Total well depth below land surface: O� (R') Submit this GW-1 within 30 days of well completion per the following:
For muhiple n-ells list all depilu if different(en-atnple.-3(q-00 and 2(au001
24a. For AU Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:
40 (ft-) lnformation Processing Unit,j1617 MSC.Ralei-h-NC 27699-1617
if uvter level it ahat-e casing.use 24b.For Inieetion Wells:Copy to DWR,Underground Injection Control(IUC)
6118 (in.) Program,1636 MSC,Raleigh.NC 27699-1636
11.Borehole diameter:
Wells:Copy to the
Air Rotary 24c.For Water Supply andb en-Loo Geothermal Return
12.Well construction method: county environmental health department of the county where installed
(i.e.auger,rotary.cable-direct push,etc.)
FOR WATER SUPPLY WELLS producin>r over IOO,000 GPD:Copy to DN'R,CCPCUA
LS ONLY: 24d.For Water Welts
Air Lift Pemr,t Program.1611 MSC,!Rale,gh.NC 27699-1M I
V�
13a.Yield(gpm) Method of test:Chlor. Tabs 4mount: 1 1/2 Lb
s
13b.Disinfection type:_----
i
Revised 6-6-201A
1 North Carolina Departmentm
of En.ironcntal Quality-Division of Water Resources
Form GW