GW1-2022-03149_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD G
For Internal Use Only:
1.well Contractor information: Var,
.W,
Alfred Kiesling Sr FROm TO DESCRiPT10N
Well Contractor Name �Eb 16 7 11 Z-I ft. 0
Uni�
2670-A
NC Well Contractor Ce"'fration"lumber G Tar. M,%TERLA.L
FROM TO UkIdETER TMHIC-NESS
B & K Well Drilling Inc ft. ft- 61/4 in. SDR-21 PVC
M-Ts us
:ANNER: -1-HICKNESS MATERIAL
. .ER-.- G:OK
Company Name FROM .1.0 DIAMETER
2.well Construction Permit 0: 17 17 ft. ft.
Lisr all applicable Kell c0llstrucriO"pc;nits i.e.UK.Corona.state slanalict.etc.j
ft. ft.
Y:
.4.Well Use(check well use): HWKNESS MATERIAL
FROM TO DIAMETER SLOT SIZE
Water Supply Well: ft (t. in.
.
ClAgricultural unicipal/Public in.
err.1denlial Water Supply(Single) ft.
015cothern`131(Real ine/Cooli Ilg supply)
Water Supply(shared)
DResidential W ALD"Ou!'I
C)IndustrizKonunercial ei i s>100,000 GPD FROM TO n-,TERIAL E_%LPLACEMF_NT METHOD&
oirrigation 0 rL 20 ft- Bentonite Pour
Non-Water Supply Well: ft.
ORc�ovcqy
okfollitorilIg ft. ft.
Injection Well:
06roundwater Rentiediation
X
0Aquifer Recharge
OAquifer Storage and Recovery ElSaiiiiiry Barrier FROM TU ro-M L MIAF,MPI".4CFMEIVT METHOD
ft.
C Aquifer Test oStormwater Drainage
CSubsidence Control
oExperimental Technology 0.44*�r._V)
DGeothermal(Closed LOOP) oTracer FROM TO DESCRIP (color.hardness.soil/rock tYpe,Ersm MM S-1
oGeothermal(Heatine 00ther(explain under#21 RemarLq) I ft. ;n -r
jqooling Return 6 f'-
4.Date Well(s)Completed: _11—La—awell fD# 167
ft. 0
Sa.Well Location: 160 ft'. ft.
ni,,,�4 Facility ID (if applicable)
Fa,itity/o%vrerNarae ft.
ft. ft.
Physical Address,City.and zip
RK
J� We 7.1-9 —
pal.ce,Identification No,(PIN)
County
longitude in degrees/roinutes/seconds or decimal degrees:
5b.Latitude and 7-2.Cerfifi a' n:
(it'v,ell field.one Wilong is%utticient)
N Simaturt Cerified mien ng this form. Wel 00tact er ate
6.ls(ar )the well(s): CPermanent or ETemporary i
that the zeIl(s)was
15A NCACO2C.010or 154 NCACO2C,02on Bell Construction standards and deal a ccry
7.Is this a repair to an existing well: C:Yes or 2 NNO ofihis rrcnrdha�5 bcrnp,,o,idrdn,th,,v.riloivner.
-
11 rhis is a repairfillow kno%r well.-anst—wein informalin),and explain the nature Ifth.,
back of thisfio-1. 2.3.qite diagram or additional well details:
repair under#21 remarks section or on the 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 h additional pages if necessary.
(add'See Ovee in Remarks Box).You may also attach
construction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONSI
drilled: d
9.Total well depth below land surface'. 7' Submit this GW-1 within 30 Aays of well completion per the following:
For alulliPle 11-clis lislall,lepits-if different fe.jantple-3(¢1_700 and 2@q 00.) 24a. For Original formto Division of Water Resources (DR),
.,
10.Static water level below top Of casing:
40 All Wells:(ft.) Information Processing Unit,l6l7 MSC.Raleigh.NC27699-l6l7
If muter level is above casing.use 24b.For il2hs62m Wells:copy to DWR.Underground Injection Control(IUC)
r
6118 Program, MSC.Raleigh!NC 27699-1636
I I.Borehole diameter: 9-am,
Air Rotary 24c.For Water
&I 1 11116; 11)en-Loon,Geothermal Return Wells:Copy to the
-
12.Well construction method: coun viron mental health department of the county where installed
(i.e.auger,rotary.cable,direct push.etc.)
i FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lloo.000 GPD:Copy to DWR,CCPCUA
.over - -
13a.Yield(gpnI) Method of test.Air Lift pernli I program, In,I MSC,:Raleigh.NC 2/(Wy
Chlor. TabS 4,mount: 1 1/2 Lbs
13b.Disinfection type'
Division of Water Rcsources Revised 6-6-2019
Form GW-1 North Carolina Department of Em ironmcntal Quality