GW1-2022-07270_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD (GW-D For lntemal Use Only:
1.Well Co°tractor Information:
Alfred Kiesling Sr 14'.M-A•MIEZ{1?41 5;:::.;>;:.>:<. ;.
FRODI TO DEFC'A7Yff0�
well Contractor Nana ([- I G v /5 S r
2670-A 0rL ft. ^�
NC Well Contractor Certification Number 153(FxTEiKh:SiN erm '.es9ed set15:E)Rii ENEit' ?;":: °' i`'
B & K Well Drilling Inc FROM TO DIAMETER TH1CI:�FSS IMATE
RL�L
`.� ) L /7/ 0 ft. 19 ft 6 1/4 i° SDR-21 PVC
Company Name V/y / (O
2.Well Construction Permit _ _ _ I P-Rom I TO utA�terER TxICKNESs 11ATER1:1L
+ fu iR
Lisr all applicable well cortsrrucdon permits .e.UIC.Coto=.Sinle.i%arioncc.etc.) 1
in.
3.Well Use(check well use): I t
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
O. cultura! ❑-Municipal/Public rc. fc in.
OGeothermal(HeatingiC'ooling Supply) 2Rcatdattial Water Supply(Single) R- fL in.
GlndustrtaContoe ru� t ORe sr de nal
Water Supply
ShareL)
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G Irrigation O Wells>100,000 GPD FROM To REAL EAIPLACENIENT METHOD&A-MOUNT
Nunn Water Supply Well: 0 ft- 20 fL Bentonite Pour
OMonitoring ORccovcry
Injection Well:
GAqulfer Recharge
o oGroundwaterRemediation -....,.. ..... ...,...,.:...:.,:;::�...,,.::.,.,::;;:::•;; >:;::::;:::.::.,.,,,.:.,.,.:::::.�.:;::,:::
::i.}�c:$:A1N•$tGi{;3Y'31�4Cl�:fil: - le}-:_:;;;;:c;qg;;;:;i:;:,�i:i::S;i':'i:;;:::::::::%:>;r>:5:;::�:5::��.:
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. F.MPI_ACEn[FM ME7H(1D
❑Aquifer Test ❑Stormwater Drainace
❑Experimental Technology ❑Subsidence Control tc ft.
>:>:;z
OGeothennal(Closed Loop) oTracer %3 ;BkEUIi3�TGrI OC attadi•'a3il iedltt #e i 3.»:i%:z::
FROM TO DB.SCRIPTI0-1(color.6ardttas, rock ¢r,mr sze.etet
OCieotbermal(Heat Return) r,Other(explain under#21 Remarks) fc fr.
55
4.Date Well(s)Completed- well rD#
Sa.Well Location:
J:nF'Y� fL
zs.Facility/OnTer Named Rd
M#(ifapplicable;
a s j L f/i . V Rd- L02 111L ft
fit.Physic I Add r ,City.and Zip ft.
e 610V 6 7
County Parcel Identification No.(PIN) I t 4; ,5�;.°i3Unq U
Sb.Latitude and longitude in degrees/min°tes/seconds or decimal degrees:
(if well field,om lat/long is sufficient) 22.Certification-
6.Ware)the well(s): !Wermaent or OTemporar
t:=2tu. ofCerined Well.Cotrz�or
n ate
drsenin�ridv7orm.1 harei!t•rerrijr that rhr ml!! uay lucre)<anstrrrrred in arcordarne::idr
7.1s this a repair to an existing well- OYes or !)No .a:.Cj.0&.Mr,or 75.+NCIC 02C 17200 Hell Cortsrrvcuoa Slandards and that a corn
!(rhis is a repair.fill out known well<»nstnrctr'oa;nfcnrarinn and erntm:.me narvrr n1 rh, ?l ribs record has Ix•en prorsdrd m rho.r/1 ounce.
repair under+`'21 reena cr section or on the back ofth:s ror,n. 23-Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells havina the same You may use the back of this page to provide additional well construction info
cons tmetion.only 1 GW-1 is nccdcd. Indicate TOTAL N I-MBER�of wcils (add'See Over,in Remarks Box).You may also attach additional pages if necessary.
domed: 24.SUBMITTAL rNSTRUCTigNS
9.Total well depth below land surface: 7 66 M) Submit this GW-1 within 30 days of well completion per the following:
For muhipie uL/ls list all depilu'if(hJferenr(trample-34i—WO'«nd 2@1001
10-Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR).
(ft') Information Processing Uttil,1617iMSC,Raleigh-NC 27699-1617
(f maer level is abo,e easing.r w
11-Borehole diameter:6 1/8 (;n•) 24b.For Injection Wells:Cony to DWR_Underground Injection Controt(rUC)
Pro5Eam,1636 MSC,Raleigh,NC 27699-1636
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 environmental health department of the county where m.;Wled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCL'A
_3 Air Lift Permit Program,1611 MSC-Ralegh.NC 27699 1611
13a.Yield(gpm) Method of test:
13b.Disinfection type:Chlor. Tabs Amount: 1 1/2 LbS
i
Form GW-1 North Carolina DiTarttncat of Ens ironatcnral Quality-Division of Warcr Rc ourucs Revised f-6-2019