GW1-2022-03928_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1 For lntemal Use Only:
1.Well Contractor Information:
Alfred Kieslmg Sr
FROM TO DECC'RiPrION'
Well Courraetor Name /V,uq
2670-A fL 0 /d�c7vaES
NC Well Contractor Cmification Number
;:;Yx:4iFt"EEi2Si1V'G: sr'mT�tciiseitaeflS':D$i3::fRF�t _
FROM TO DikvIETER THICKNESS MATERLAI
B & K Well Drilling Inc
0 ft- 16-0 ft- 6 1/4 In SDR-21 1PVC
Company Name U /
tea�j.`mo d Y %:1&3 R C§Sit f' FlBEY�.
FROM TO D1A}1h rEK THICKNESS M1tATEKMATERIAL2.Well Construction Permit#
Lice all applicable well oorssrruc'tion prrnits .a.U!C'.C'orum�.Srarx.t•'ar.'ance.etc.7
ft. I fL in
ft_ ft. in-
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZH 1 THICKNESS I MATERIAL
OAgricultura! OMunicipal/Public ft. fL is
❑Geothermal(HeatineiCooliug Supply) 24idential Water Supply(singiei ft_ IL in
OIndusma o nl mercial ORes dn i ra]Water Supply(share
d)
❑Irrigation O We]ls>100,000 GPD FROM 1TO •L�TERIAL EntBLACfsvuz_'TMETHOD&.MOUNT
Non-Water Supply Well: 0 ft 20 fL Bentonite Pour
Oklonitoring, ❑Rccovcry tr. ft.
Injection V6e11: ft. ft.
❑A uiferRecbazge OGrouudwaterRemediationX.
OAquifer Storage and Recovery ❑Salinity Barrier tRom To MATERIAL, f.MPI_ACEM1tFJVf METHOD
❑AquiferTect OStormwaterDrainam rL fL
OExperimemal Technology ❑Subsidence Control fL it.
OGeothemml(Closed Loop) OTracer Z PRh.EiNGE4G' ii ck•`a Reii # :>;t%:::i%><;<>%s»>?>?s::;>:<::;:!rc ''
FROM TO D ON(ootor.Cattiness r?�set erel
❑Geothermal(Heating(Cooline Return) ❑Other(explain under#21 Rematis) fc. ft.
4.Date Wells)Completedr '3 • 2—Well TD# /� R. � ft. V, �� fl
Sa.Well Location: fc. 90 fL 1 .0 I9
ft. ft. r
Y 14 C
Faciliry'fOe erName Facility MT)6fapplicable; ft. fL y�
r y
fr. fL _
fL -
Physical Address.City.and Zip
'Rh34#Al2
� t42Jii':
County Parcel Identification No.(PIN) �-
5b.Latitade and longitude in degrees/minutes/seconds or decimal degrees:
(if-ell till,one lat9ono is sufficient.) ? w ��
2;�Certfflcaon:/
N R ^
6.Is(are)the well(s): OPermanent or ,Temporary ccnifi&well C nmctor Dam
Brsigning this>brm.7 herehr rerrO:rhar 62P ivell(s)was(were)constructed in accordance:rich
7.Is this a repair to an existing well: C:Yes or !nNo l+.a.VC:AC 01C.0701)or IJA NCaC'02C.n200 Well Corcrbmcrion Standards and that a corn
yf rhis it a repair.fill our known well rnnstna:rion in.lblMaiinn and exPlair Me namrr of the n(rhic trend has born proridcd m rho•.rll owner.
repair rarder 121 remarks secdon or on the back ohlris/arm.
23.Site diagram or additional well details:
8.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
construction.only 1 GW-1 is nccdcd. Tridicatc TOTAL NLTMBER of wells (add'See Ovee in Remarks Box).You may also artach additional pages if necessary.
drilled: ( _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacel�� (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple ue[ls list all depkbr if riffferear(trample-3(41200 and 2@io0�
24a. For Wells: Original form to Division of Water Resources (DIA'R),
10.Static water level below top of casing:40 (it.) All Information Processing Unit,1617 MSC.Ralej-^h.NC 27699-1617
!j iurtxr textl u•ubvre casing.re,•x"+"
tl_Borehole diameter 6 1/8 (in-) 24b.For Injection Wells:Cony to DWR_Underground Injection Control(IUC)
Program,1636 MSC,Raleigh.NC 27699-1636
11.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 emirartmental health department of the county where tnctalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water"Veils producing over IQ(1,00(1 GPD:Copy[o DW'R,CCPCUA
13a.Yield(gpm) 3� Method of test
Air Lift Permit Program,7611 MSC,RalrLgh.lvC 27699 161 t
13b.Disinfection type: CflI01. Tabs Amount /2 LbS
Form GW-1 North Carolina Dcparrment of Eniaoamcnral Quality-Division of Wwc.,Resources Revisal 6-6-201X