GW1-2022-05645_Well Construction - GW1_20220610

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:'JELL CONSTRUCTION RECORD (GW-1) For Internal use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
FROM TO D�CRiI'rI0\
Well Contractor Name ft. ft.
2670-A fL o .........
.,' o�-
NC Well Contractor Certification Number :l7ys.'. TER. '' �. e:m, 9 ..,. ..;:Ogi1LtQER
B & K Well Drilling Inc FROM TO DitivtETER TeIC14�E55 ittATERL�L
p ft. �� ft- g 1/4 i° SDR-21 PVC
Company Name
HI
2.Well Construction Permit#:l.LL� "D! 7 3 1 FROM 1 -1'0 DIAt1ErER TCKNESS hrAT�RI tL
ft. fr_
Ltsr ell applicable x,all cot+stmcdon permits;i.e.LTC.Comity.Smte,Marian x.cc.)
1°-
3.Well Use(check well use):
`:LT.:SGEEPF`"r
Water Supply Well: FROM TO DIAMETER CLOT SIZE. THICKhF.55 MATERIAL
OAgricultura! O�MunicipaUPublic ft. I fL I is
OGeothermal(HeatineiCooling Supply) 2Restdential Water Supply(single] rc- fL m
Glndusm.a Connlerrlal
ORLS1L C nttal W ;r Supply
(
shrd)
0Irrigation ❑wells> 10Q,000GPD FROM TO K%TsRTAr EMPLACEMEKTMETHOD&iMOUNT
0 rL ZQ fL Bentonite Pour
Nun-Water Supply Well:
0monitoring ORccoccry ft. ft.
Injection Weft. tc.. ..:. tt.
0 ElGrouudwaterRemediation
OAqutfer Recharge :fi41�'&GR3kF1>i?:Kf��6f
OAquifer Storage and Recovery ❑SalinityBarrierBaer FRonl To MATERIAL.
F.MPL,CEMENT METHOD-
OAquifer Test OStormv.ater Drainace ft. R-
OExperimental Technology OSubsidence Control tc fc.
_..... ..
OGeothermal(Closed Loop) OTncer 3 'BR LING: Ott attadiiiw zki� '3FsecesasixJ
FROM TO DESCRIPTION(color.hard sorVrxlt PriRl si'zt erel
❑Geothermal(Heatinz(Cooling Return) OOther(explain under=21 Remarks) ft fj"ft. 19 ( 0 / �J11
well rD# ft. 4 ft. Nl 15iO
4.Date Well(s)Completed.
5a.Well Location:
�'7r-Yp�•/� Olsu) ���CII ft fL
Facility/0"erName Facility M#Ol'applicable; ,
1 ` � fr. l ft.
1, L/ �r.Stu✓ems 63,,,,a�. �/ JUN
a. ft
Physical.Address,City.aid Zip
'-2i iLE1f�A -5
(rotary. Pared Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Certifie lion• 77
W �^
Sim uu ofCeni!ied well .onzc:or Date
6.1s(are)thewell(s): lFermauent or OTemporary
dy si�nin�!i�:c tbnr.1 herei•t•reali(.t'that rtie+:rll(sl+ens(uPre1<»nsrrurred in arcnrdmtrr:virh
7.Is this a repair to an existing well: OYes or !]No ::A A'CAC 2C.010r or 15:NCAC 01C.n10n wdl Coats vcrotr Standards and that a cvm
1)'rhis is a repair.fr!l nor known well rnnstneerntt in(ortratinn end ern/atr.the namrF nJ tit^
of this roenrd has brer,prorided tn'l.rhr nrll owner.
repair wider c911 remarks section or on the back orthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction.only 1 GW-1 is needed. Indicate TOTAL N%T.'BER of wells (add'See Ogee in Remarks Bos).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: P,,5� (R•) Submit this GW-1 within 30 days of well completion per the following:
Fur muldpie❑ills fist edl deptlu ifdifferent(erample.-3(a1.200 anel.3@ 001.
24a. For Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft•) All Information Processing Unit,1617 MSC.Raleigh-NC 27699-1617
Ij n'uter level a abo+'e easin,,.mw '+..
Ll.Borehole diameter 6 1/8 (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh;NC 27699-1636
1_.Well construction method:
Air Rota 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e.auger,rorvy-cable.direct push,etc.) comity environmental health department of the county a here uL.;Wled
FOR WATER SUPPLY WELLS ONLY: 21d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a Yield(gpm) l2 Method of test:
Air Lift Prrmrt Pro=ram,16t 1 MSC.Raleigh.NL:27699-161(
13b.Disinfection type ChlOr. Tabs 4mounL- 1 1/2 LbS
I
purees Rwised
Form GW-) Noah Carolina Dcpanmcnt of En,iroamenral Quality-Division of warcr R h 6-?Ol>t