GW1-2022-05648_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-11 For lntetnal use Only:
1.Well Contractor Information:
i .. Z01Y�.c.....:» ;:»
Alfred Kiesljng Sr , .. , >
FROM TO D)^c('Rt1rf'10�
Weil Courmetor Narr e
2670-A
/1 t'Tt ft.
NC%Yell Contractor Certification Number <Vl/. ca9eijsej)s'`OS1 ERER
B & K Well Drilling inc FROM TO DIAMETER IH1ClGtiE55 MAIERLAL
10 ft. I J Z ft. 6 1/4 in SDR 21 PVC
CompanyNnme :?; 'E TfSENf':E : >z :i '.
2.Well Construction Per•mit;*•E �'o g� rizoM UlA\1EfER Tu1CKnrSS MArERI:+t
• ft. 1 tt In.
Lirr all applicable well construction pcnrits .r.UIC'.Corurty.Stare.6an*aircc.elc.)
ft- ft. in- I
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNIMS MATERIAL
❑Agricultuta! ❑�MunicipaUPublic k. i ft ia.
CGeothermal(HeatineiCoolin ,'a
g SipPly) <dential Water Supply(Single) ft. fL in.
OlndusLrial/Conntercial ❑Red• e ttal Watt-Supply(Share L)
a iGlifi! •;;:. z: :.
EASPLAC '\T METHOD& MUUNT
C Irrigation ❑W el Is>100,000 GPD FRU'tI TO rL�TERL�I. h
Nun-Water Supply Well: 0 fL 20 ft Bentonite JPour
CNlonitoring ❑Ra:oecry ft. ft.
Injection Well: ft. Ir.
l7AquiferRecharRe 0CirouudwaterRemadiatior. � �}
CAquifer Storage and Recovery ❑Salinity Barrier FRo3I To MATF,RIAI. EMPI-ACEMENT METHOD
CAquifer Test ❑Stormw'ater Drainage fr. ft
OExperimentak Technology ❑Subsidence Control ft ft.
oGeothermal(Closed Loop) :FR'BRi LiNG;fI]t 'stt:cha DESCRIPTION
......
❑Tracer
FRO TO DE-SCRIPTiO�teobr.Gardners© k -.•.sr�sza acl
QGeotbermal(Heatine/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. 5-
4.Date Well(s)Completed. 2.Well ID# ! ft. ft. / 0 li/ 0
ft. ft.
Sa.Well Location:
fc.
Facilityto"er Name- Facility M#(ifapplicable} 60 R.
r ft. ft
/ Le IL ,rW CV✓>c 64 i
ft. n .����',�Q
Physical.Address,City.and Zip _
G
'04 g 1 S l3
county Parcel Identification No.(PLN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifv.•cll Tidd,one 1at71ona is sufficicni) » �Il'`fOfi r�'�'+-1 ?i 'Cw ';� Ung
Certific on: r tv
w J'. �f�t2G
c
6.ls(are)the well(s): nPermanent or ❑Temporary
Situ rCnined well Contra or Date
dr sr^rinS tiio}Dire.J iterei!t'reni!i,that rhr+mll(sJ,vas(ivrroJ<onstrurred in arcardmx-e:pith
7.is this a repair to an existing well: GYes or nNo ::.,VC C p'C.OJOr ar 75.,.NCaC 02C.n2on Well Cactmtcra,:Standards and that a rim'
V'rhis is a repair.fill out kno-r.weli cnnslnd rz;ma in(oaratinn and ern!oir.th"aarurr of rm
of trtir record has beer,proi-ided to rhr vrll owrer.
repair under#21 r_mra:ks section or on the back ofzhis loan. 23•Site diagram or additionaFwell details:
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
construction-only 1 GW-1 is needed. Indicate TOTAL NUMBER of v.+cils (add'See Over'iu Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24 5_ O Submit this GW-1 within 30 days of well completion per the following:
Fur mulripir hills list all depilu if ckfferral(,rumple.-3tSC,00 RRdl 1(4000
10.Static water level below top of casing:40 24a. For All Wells: Original's form to Division of Water Resources (DWR).
(ft) Information Processing Unit,1617 MSC.Raleigh.ATC 27699-1617
t writer level is abot-e casing.use"+"
il.Borehole diameter:6 1/$ (in-) 24b.For Iniecfioa Wells:Cody to DW'R Underground Injection Control(IL1C)
Program,L636 MSC,Raleigh,i�C 27699-1636
12-Well construction method:Air Rotary 24c.For Water Supply and Opera Loop Geothermal Return Welts:Couy to the
(i.e.auger,rotary.cable.direct.push,etc.) county environmental health department of the colmry udtere imstaned
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over 100A0 GPD:Copy to DWR,CCPCUA
1611 MSC.Raleigh-NC 27699-1611
13a.Yield(gpm) :117 Method of test:
Air Lift Permit P ogrrm,
Tabs . 1 1/2 Lbs
13b.Disinfection type:Chlor. Amount.
Form GW-1 Nonh Carolina Dcpanmrcnt of Emaon=ntal Quality-Division of water Rcvoiucc: Rc�iscd 6-6-2019