GW1-2022-03938_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD (GW-1) i For Internal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr ..
ZO
FROM TO DE.�t:'Rn'1T0�
Well Conrrattor Name ft. /7Q ft.
2670-A V
a p
NC Well Contractor Certification Number � <,
.:...?. ...,.,, ...:.
B & K Well Drilling Inc I FROM I To I DLLv1ETER I THICKNESS I MATERLAL i
Company Name 10 e. 13� ft. �6 1/4 'a- SDR-21 PVC
2.Well Construction Permit 0: M I h-RO I •to uiA F-r8R THICKNESS MATERf>L
Line all applicable wa11 consmartion permits,5.r.OTC.Corutn.State.fariaircc'er<./
ft. ft.
3.Well Use(check well use):
i T 3t3�EEPfr;
Water Supply Well: FRONT TO DIAMETER SNOT SIZE TNT(KNESS M.>TEKIAI
OAgricultura! ❑Municipal/Puelic ft. I fL
❑Geothermal(HeatingiC'ooling Supply) a<dential Water Supply(single) it- rc
❑indusmal/Cornmercial OResidential Water Supply(shared)
C Irriggation ❑Wells>100,000 GPD FROM I TO NQ TERL%L E-IIPLACEMEN7 METHOD&.iNtOUM
Nun-Water Supply Well: 0 fL 20 ft- Befltonite Pour
0MOnitorinr ❑Rccovcry ft. I ft.
Injection Well: i
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery OSaliviry Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) OTracer 7#'>BRiLIhTi!=4iCi7gtaechaiieDsTiefS[ s«es ;;>::%'><
FROM TO DESCRIPT[ON(color.hardness sontrock ?rear sizes ern)
❑Geotbermal(Heating(Cooliag Return) ❑Other(explain under=2l Remarks) I ft ft —
4.Date Well(s)Completed- I Well ID# �' �
5a-Well Location:
ft. f6
ft. ft.
LFa/cili/•/(�hwrerNjam Ti)z �j ]� /f Facility #(ifayplicable; ft' fr"
Z / ft. ft a.
Physical Address,City. Zip a ft. I ft.
County ?=cl Identification No.(PiN) 2`'
5b.Latitude and longitude in degrees/minatesiseconds or decimal degrees: " '
(ifu•cll field,om lattlono is sufficicotl
22.Cc tali �;° '�!C�rr`"-i ftiaj PRO
N �' f
6.1s(are)thewell(s): (nPermanent or ❑Temporary Sim wure Cenitied Well Conzactor Date
2rsrgrinS trs for m.1 hrreP,re r fr t zest rnr,:rllrsl nay vPrn),onstrucred in acrordanre,:ir1r
7.Is this a repair to an existing well: GYes or JNo 5. NC.?C&.01D0 or/5. N`C,4C 02C.n200 ftr Corctm troth Slandards and that a cam-
1/this is a repair.fill our know well ranrtrucrtaa infornrarmn and etnlara rhr narurF n(rhr ?/rhis recnrd has&teen prm'ided to rhel-11 otmer.
repair render#21 remarks secCon or on the back ofNiis;orrn. 23.Site diagram or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells hating the same You may use the back of this page to provide additional well construction info
construction-only 1 GW-1 is needed. Indicate TOTAL hITMBER-of wells (add'See Over,in Remarks Box).You may also attach additional pages if necessary.
drilled. I — 24.SUBMITTAL INSTRUCTiONS
9,Total well depth below land surface:- /Da2S (fL) Submit this GW-1 within 30 days of well completion per the following:
Fur atu trip ie ur1/s list all depdo if&fv-enr(example-3(e,_00'and 2rd.1001
10.Static water level below top of casing-40 (fr 24a. For AA Wells: Original form to Division of Water Resources (DWR),
ff tt'rrrer lair/is ubuve casing,use'+"'
Information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
11.Borehole diameter: 6 118 (in) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
Program,!636 MSC,Raleigh,NC�27699-1636
Air Rota
72.Well construction method: Air
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable.direct push_etc.)
county emironmental health department of the county inhere insW led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over i00.000 GPD:Copy"to DWR,CCPCUA
13a.Yield(gpm) J Method of test:
Air Lift Permit Pro_ram•1611 MSC.Raleigh•NC 27699-16I 1
13b.Disinfection type: Chlor. Tabs Amount. 1 1/2 Lbs
i
Form GW-1 !North Carolina Dcpanmcnt of En,ironmcntal Quality-Division of Warcr Rccourccc Rcviscd 6-6-301 x