GW1-2022-05749_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) For lntemal Use Only:
I.Well Contractor Information:
Alfred Kiesling Sr ......
FROM TO
Welt Contractor Name ft.
2670-AT-
NC Well Contractor CerTiflcation Number
B & K Well Drilling Inc FROM TO,0fr � rER I THICK-NESS MATERIAL 5- L 61/4. SDR-21 PVC
Company Name X
2.Well Construction Permit.",: %3-A lFrER THICKNE&q MATERIAL
List rll applicable well coyarpictiwi permas 4.c-,UIC.Colvirv,Stnte.VaT4—cc.01'..) ft. i fL in.
3.Well Use(check well use)-' R- ft. in.
Water Supply Well: FRONt 1 TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
ChAgrlcultum! O-Municipalfl?ublic ft. I ft.
DGeothermal(Heatin_iCool ilia Supply) 2<esidenliai Water Supply(single]
ft- ft- in.
01ndusnizKoniniercial OResideniial Water Supply(sliared)
01rrigation OWells>100,000 GPD FRO51 MATERIAL VNIPLACE-ME
Nun-Water Supply Well: 0 120 1 fl- Bentonite Pour
DMonitoring ORc ovcry I ft-
Injection Well: ft. I ft.
CAquifer Recharge 06roundwater Remediation ............
X .........
OAqaifer Storage and Recovery ClSaliiiiry Barrier FRGAI TO MATERIAL EMPIACENIENT METHOD
CAquifex-Test ostormwater Dramace ft. fr. I
OExperimentail Technology OSubsidence Control
CGeothermal(Closed Loop) OTracer
FROM TO DESCRIP77O�(mbr.tiara soiVroek... .?ram size.eras.
CGeothermal(Heating/Cooling Return) 00ther(explain under#11 Remarks) , 0 f,. _,�,�.f,.
4.Date Well(s)CompletidnYll�2-2- Well ID# 'kO,4- ft. In
rr-k-, ,fo
5a.Well Location: L/7 r
0 1 t
0321� tk
Facility/CixvrerName F,�cilijv M#(ifapplicable,, fr. fL
eo2-= 010 C4,ILI L 14 L b(. cz ft-
Physical..Address.City.atid Zip fr. ft.
County ?a.,ccl ldcwificariclo No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one latflong in sufficient) 22-Ce a k
N W
A
6.ls(are)the well(s): [nPermaaent or 01remporary ll DM
Br signing th&.than.I ll—rby rtrqf
7.Is this a repair to an exMng welt C:Yes or !]No .;.;.4.-V CAC 02C.ojonor l5.4,NC,4CO2C.n200 IT'et7 Construction Standards and that a corn-
!frhht is a repair.fill nur kno>r well ennstria.-ficm W;rmwfinpi and the njrvrrnfihr ?(this recnrd has been prodded to the v.r/l owncr. J U N 069 2022
repair roider#21 remarks section or on the back q67dt.rom. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this Oagge to Drovide Unk
constracton.only I GW-1 is needed. Indicate TOTAL NUMBER ofwclis (add'See over'in Remark:,Box).You may also attach additional 1900,W)Gly
drilled: 24.SUBM! MAL INSTRUCTIONS
9.Total well depth below land surface:. ,
For multiple lix-lis list all depilis ifeftfferent(erample-3,qCOO amet 2@V001 Submit this GW-1 within 30 days Of Well completion per the following:
10.Static water level below top ofcasing-40 24a. For Al! Wells: Original form to Division of Water Resources (DIA'R).
Information processing unit,1617 MSC.Raleigh-NC 27699-1617
ffmaer ere above Casing. ,-+- -
11.Borehole diameter:6 1/8 24b.For Injection Wells:Copy to DWR-Underground Infection Control(lUQ
Program,1636 MSC,Raleigh,.NC 27699-1636
12.Well construction method: Air Rotary . I
224c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the counryatere installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift i Permit Pro--i-lim,1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina DTartmcnt of En.irominclital Quality-Division ofWarer R-ourz:es Revised 6-6-20 1 A