GW1-2022-05647_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Lntemal Use Only--
1.Well Contractor Information:
Alfred Kiesling Sr FROM r
FROM TO DgcCiZtytTO\
Well Contrdcror Name ft. 3 W
2670-A fL ft.
NC Nell Contractor Certification Number 6'tL( tTERE 1:43Y ai mii .c84ed;$el £)$i3 CtQE '
FROMI TO DWMETER THICKNESS VIATERLkL
B & K Well Drilling Inc
0 ft. I I ft. 61/4 1° SDR-21 PVC
Company Name 71z:3i41VBRE TO
MOM N
SF1?&>( FSSFI mat'
r I I DIA '-rER THICKNESS MATERIAL
2.Well Construction Permit#:1 Z Z Q 1 ft in.
Live all applicable well cottfmlction peer-its 6.e.UIC.Corarnt Suite.11an.'mrce.e1c.)
ft. I ft.
in.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural 0-Municipal/Public it. ft I 1°
OGeothermal(Heating 1a
icooling Supply) <dontial Water Supply(Single) ft. (L in-
>::.;^:::<;»;>::;::>:
Glndusrnal Contnterrlal ❑Res de teal Water Supply y(ShaleL
�
Girriaation ❑Wet Is>100,000 GPD FROM TO MATERIAL Efi1PLAC fE_Tv7 METHOD&11:�fUUNT
Nun-W2ter Supply Well: 0 rL 20 fL Ben'tonite jPour
GD4onitoring ORccovcry tr. ft.
Injection Well: ft fr.
❑Aquifer Recharge OCirouudwater Remediation ...,....: :.... .....::::..
<>ti'>::i:':':;;;:•z�isi?t:::>:<;:
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL F.MPIACEMENT METHOD
OAquifer Test ❑Stormwater Drainace ft. ft
OExpetimental Technology OSubsidence Control rc ft.
❑Geothermal(Closed Loop) ❑Tracer
:21#'�Bii:ELF;11ti�if:�OC'attacti'ae>iirl �#saEs�s ...::..:.::.,,..::::..:.
FROrt TO DESCRSPT[ON(color.turdnecs wtV k zr+in rize.ere.)
oGeothermal(He ating(Cooling Return) OOther(e.tplain under#21 Rem ael s) ft. Z fc• /,,
4.Date Well(s)Completed: v2 7 2-'A—Weil ID# ft' � ft `-- w (Alz
it. 0 ft-
ft.
Well Location:
/I 1 II lD fL13 ft �, � ►'
11r �N� ce y r3 erttc��µrt t aw r
FacilityiT (ifz licable; tr. r! ft
Facility/Ocvrer Name Pp V'
L 1 ft. ft
LC t�t53� WeIN illy -
Physical Address.City.and Zip ft. ft r
C3, Sc r zz�
County Parcel Identification No.(PLN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , , P
g
(ifvcll field,one latlong is su�cicnt) 22.Certification: � �Infoff7irr9�lrt'y91 P�•�r^:rtiye'?` Unr
r,Jial�.(i BUtz j`'
Nj W i-�J `;"-,
6.ls(are)thewell(s): JPermanent or ❑Temporary
S;�-4 fCenitied Well .onmctor 1e
drsrerino fhi<jonn.i heron rernjt near the.rllrsJ rv'a$(Ivere)<onstrucred in arrordanrr'•ith
7.Is this a repair to an existing well• GYes or !lvo :9.4 XCv.0 02C"010r or/S.;,NC.4C 02L.0200 it'eA Cort5mcliOl?Standards and that a earn-
!!This fs a repair.fill our knonr.well rnnstnrclt'an infonrarina and ernla",,rite narure of rim air h record has IXr rr proridrd m rho rrl!ounce.
repair raider#21 remarks seccon or on the back orrhis form. 23.Site diagram or additional well details:
Geothermal Wells having the same You may use the back of this page to provide additional well construction info
S.For t;eoprobe/DPT or Closed-Loop
construction-only 1 GW-1 is nccdcd. In icatc
Gent TOTAL llMBER-of cllsa (add'See Cher'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For muhipie,mils list rill depdu iiMferenr(erample-3(a�_00'and 2(dti00j
0.Static water level below top of rasing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft-) Information Processing Unit,1617 MSC.Ralei^h.AIC 27699-1617
If outer level is ubor'e casing.use—
6 1/8 24b.For Infection Wens:Copy to DW'R Underground lnjection Control(TUC)
11.Borehole diameter: {in.) Prosram,1636 MSC,Raleigh.!NC 27 699-1636
12.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 ennironmemtal health department of-the eotmty uthere installed
I
FOR WATER SUPPLY WELLS ONLY: 24d For%Pater Wells prodticina over 100.000 GPD:Copy to DWR,CCPCUA
Permit Prouram,16t 1 MSC,Raleigh_NC 27699 161 t
13a.Yield(gpm) w Method of test:Air Lift
13b.Disinfection type: Chlor. Tabs Amount: 1 1 I2 Lbs j
Form GW-1 North Carolina Department of En,ironmcntal Quality-Division of warcr Reslourccs Re,,iscd 6-6-201 x