GW1-2022-05662_Well Construction - GW1_20220608

CONSTRUCTION RECORDIGA-1) For Iriterrial Use Only:
1.Well Contractor Information:
:777!
Alfred Kiesling Sr
FROM 0
Well Contractor Name
2670-A fL ft. 7-
NC Well Contractor Certification Number
FROM TO DIA.XETER THICKINESS MATERULL
B & K Well Drilling Inc 0 `7 6 114 SD. R-211... PVC
X.:
Company Name OWTURL
2.Well Construction Permit: 49.1 S rO DIAVIF 'R THICKNESS TERIAL
_ ft. I! in.
L&,all applicable At'll c;&hsMJc6011 PO"'rits 6"-e.UIC-Colul".State.110"a"Cc.d1c.) ft- I fc. in-
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_RIAL
O.A.gPicultum! cllmunicipatl?ublic ft.
OGeotherrn3l(HeatiiisEiC0Oli1Ig Supply) 2<dvilial Water Supply(Sill.-le) in.
01ndustrial!COnunercial oResidential Water Supply(shared) W.,
Oirrigallon oWells> 100,000GPD :F::RO�1 TO6aCi�MET*ff'OD&A-MOUNT
Nun-Water Supply Well: Q rt120 ft. Bentonite jPour
tr
Okloiiitoring E]Rccovcry
Ejection Well.
OAquifer Recharge OGroundwater Rernediation
...............
...........
0 Aquifer Storage and Recovery OSaliuiry Barrier FROM TO MATF,RIAI. EMP ACENIENT METHOD
CAquifer Test oStorinwater Drainage
OExperimentall Technology OSubsidence Control fL
CGeothermal(Closed Loop) OTracerBRL 400G:
FROM To DESCRIPTnix toolor Hard -.11-1,ripe.era in mm«c II
OCieothermal(Heating(IC=� ling Return) 00ther(explain under#21 Remarks) pY ft ft.
A�P I YJ
4.Date Well(s)Completid,Sh 7— Well ID# IIT ft
ft.
2 -5 ft-
Sa.Well Location. 4V
1�k ft.
Facility M#(ifapplicable! ft. fL
Facility/ Her NarnefL
Physical Address.City.and Zip
County Pa nclIdentification No.(PLN)
5b.Latitude and longitude in degreeslminutesiseconds or decimal degrees.
(if well field,one iat/long isnufficicno 22.Certffica on:
6.Is(are)the well(s): OPermanent or OTemporary ijed Well Cone I or Date
.1herel-­?70.Thal rhp%t,/l(S)seas(ivere)ronstrueredin atc-ordanz e 1:ah
z Standards and that a com
7.Is this a repair to an existing well; C:Yes or !]No
Ifrhhv is a repair.fill out kno%7,well -'rifortrafirin and vmtarr.the narurrnfrh� vffhis record has brat to.rh,,-rll o,mer.
repair rinder#21 remarks sec.don or on the back ofilds.rom. 2.3.Site diWarn or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this ipage to provide additional well construction info
construction.only I GW-1 is needed. Indicate TOTALINI-TMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL rNST-RUCTTONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For inutripiv iitis list aff dep&s-ifthffe-rent(trample-3(C,!_W0 and 2@j,?0j
10.Static water level below top of casing:40 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1 617 MSC.Raleigh.NC 27699-1617
ffivater level is abo-e,casifi,•mye
6118 24b.For Injection Wells.COPY to DW"R_Underground Infection Control(rUC)
11.Borehole diameter- (in-) Program,1636 MSC,Raleigh..INC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply 1 xm-Lol� 3,Geothermal Return Wells:Copy to the
(i.e.auger,ToEasy.cable.direct push,etc.) county environmenralbealtlideparnne ofthecountY where installed
FOR WATER SUPPLY WELLS ONLY: 24d.F!Q.Vater ItV�11.s producing over 100.000 GPD-Copy to DWR,CCPCUIA
t _Tarr�,T -1611
61 �j
13a.Yield(gpm) 5W Method of test:Air Lift I'LrmF I MSC,Raleigh-NC 2769sx
13b.Disinfection type: Chlor. TabS Amount: 1 1/2 Lbs
Form GW-i North Carolina Duparrincrit of 5n%iroamenral Quality-Division of WaTcr RcsOurci:S Revised"-201 A