GW1-2022-03148_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1] For lntemal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
r 14::13"X•t 'RZO.�#`S ;-. .
gFR'01�1TO DESCRIPTIONNell Contractor Name `- 0 ft.2670-A f=tB 1 6 7ozz
ft.NC Well Contractor Certification Number •�. ,..,- ^;.^- i '+ U FASiKQ ioraatrt caseilivel>s Ej�x'• TO DLLWETER THICKNESS MATERIAL
B & K Well Drilling Inc•' D%NNQ� oft. ft- g 1/4 i SDR-21 PVC
Company Name
2.Well Construction Permit#: 4 t /' Q '7- FROM to DIAMETER THICKNESS MATERIAL
% ! t%ariauCa'.e7c'. ft• ft. in.
List all applicable well coiarruction permits.t.c'.C!C'.Cotam.State. )
ft. ft. /n.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER I CLOT SIZE THI(KNESS MATERIAL
❑A&icultural ❑MunicipaL'Public ft. ft.
EIGcothermal(HeatinJCooling Supply) OReside itial Water Supply(single) R. ft.
❑Industrial/Commercial ❑Residential Water Supply(Shared) Y8ilafttml ?'
❑irrigation ❑wells> 100,000GPD FROM TO I MATERIAL E.At.PLACEMMEKTMrM0D&/rMOUNT
Nun-WaterSupply-Well: 0 ft. 20 fL Bentonite Pour
❑monitoring ❑Recovery
Injection V4e1L ft. ft.
❑Aquifer Recharge ❑<irouudwaterRemediation ;p9&AN9Gi1� EYFd
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACEMF7Yf METHOD
❑Aquifer Test ❑Stormy ater Drainage R. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :1)RLEL33YG.L4G sttscha4di4tiazl°L�teab'#.e,xcssalx.
FROM TO DES IPTION lor.hardness.soil/rwk .gram ma Fret
❑Geothermal(HeatinJCooling Return)
/'❑2Other(explain under#21 Remark) ft.
4.Date Well(s)Completed:'-� ` Well ID# ft.
Sa.Well Location:
ft. t. �2 t
0 _...L Ae ern is _
ft. ft.
Facility/Osv7+or Name
, /I Facilittym (ifapprlicable)
L e� l�o Sn•s riT�t la—� 7 ft. ft.
Physical Address.City.and Zip
q SS 2i:RE1SaaR S.
County ?arcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well ticld,one latilong is%utiicicnQ 22.C c •on �•
N
W
Signat ofC tided eItContractor Date
6-is(are)the well(s): OPermanent or ❑Temporary -
Br Vining this jonn.I herehr cenift rhor the+:vlllsl+vas(were)ronsrruered in a<rordan<a,rirh
7.is this a repair to an existing well: ❑Yes or PJNo l9.4:vCAC 02C.Olnn o>lS.d A'CaC 02C.0200 Iteell CatLtrruCriali Standards and that a cqm:
of this record has been provided m the o.oll owner.
lJ this is a repair.fill outknosrt well<»nstnrclimt irsfonnarimt and explain the nature afrhr ,
repair rarder#27 remu:ks section or on the back of this form. 23-Site diagram or additional Nvell details:
You may use the back of this page to provide additional well construction info
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add,See a.er'in Remarks Box):You may also attach additional pages if necessary.
construction.only i GW-1 is needed. indicate TOTAL NUMBER of wclls
drilled: 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: O049tr (ti') Submit this GW-1 within 30 days of well completion per the following:
Far multiple n,ells lisl a0 depths if different(Trample-3(ar_00 and 2@10(f)
24a. For All Wells: Original'form to Division of Water Resources (DIA'R),
10.Static water level below top of using:40 (ft-) Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
if nvrer level is abot a casing.use
6 1/8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11-Borehole diameter: (in-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method•Ai r Rotary 2-4c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county enNzronmental health department of the county where m.-taijed
to DVt'R,L'CPCUA
FOR WATER SUPPLY WELLS ONLY: 21d.For Water Weds producing Deer 100.000 GPD:Copy-
Air Lift Ptm rrtProgam.1611 M SC,Ralelgh.iNC 27699-1611
13a.Yield(gpm) Method of test:13b.Disinfection type: ChlOr, Tabs Amount: 1 1/2 Lb
s
1 ,
Form GW-1
North Carolina Dcpanmcnt of Ern ironmental Quality-Division of Water Resources Revised 6-6-1019