GW1-2022-07275_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For Lntemal Use only:
1.Well Contractor Information:
Alfred Kiesling Sr
Well Contractor NameFROnI TO DESC'RiPiTO\. A.
2670-A 3 Oft. / h. n
NC Well Contractor Certification Number 4® ft © ft '
74 r
B & K Well Drilling Inc AI
FROM TO I DIAMETER THtCIChE55 1HATERLIL
Company Name v A Q fr• 16 1/4 1 SDR-21 JPVC
O 9 C/� 2fI-N RG
2.Well Construction Permit 9: FROM ro DIA.MErER JMLKNEss MATERIAL
List all applicable well corrstruc6otr permrtT 5.e.LUIC.Corurrv.Suite.P%7 0ncr.etc.) rt. j ft in,
3.Well Use(check well use): ft ft. in.
Wafer Supply Well: a:Z.Sc3i€EN ;. ....»::
FROM TO DIAMETER SLOTSIZE THIC ESS KIN MATERIAL OAgricultutal OMunicipaUPublic ft• ft in-
OGeothcrrnal(FieatinviCooling Supply) �dential Watel•Supply(single]
ft- ft is
Olndusaiai/Commercial OResidcntial Water Supply(shared)
z:rlr;::rf33fl><i?F:ii:`i<<li;;:E :;i:>'6i:i:;>:<: i;:;.i:: 1;;i:::`i>i> 'tsais»::;:;:.;::•:;:
01nrigation ❑Wells>1 U0,000 GPD FROM TU MAIEtrrAT E�rPLACEKE\7 METHOD&.LNrOUNT
Nun-n-Water Supply Well: Q ft 20 fL Benton ite POUF
ONIonitoring ❑Rccovcry f(.
Injection WetL t
t.
OA uifer Recharge OGroundwateT Remediation ft ir-
❑Aquifer Storage and Recovery OSalinjty FRU�1 TO MATERIAL Barrier �l dif3f hMATP
ER1A I. EMPL>CEMFM METHOD
OAquifer Test ❑Stormwater Drainage ft. ft-
OExperimernal Technology OSubsidence Control ft-
ft
❑Geothermal(Closed Loop) OTracer
-fat
❑Geothermal(HeatiWCoolin-O Return) ❑Other(explain under#21 Remarks) FROM To DESCRtMoN(color.EardneSU roNc size«�I
ft. ft. lif 1
4.Date Well(s)Completed:-2��7- -well W# ft c� ft. 0
5a-Well Location: s ft. ft
a Mks ft. ft.
Fac,hty/Goner Namz - Facility M`(ifapplicable; ft. fe
is a a h� ,P��dse �o Zz : V
� x
Physical Address,,City.and Zip g, ft.
1 D i'Z REllIRRIi�Si:i;i:
County Parcel Identification No.(PIN) 1foOM /•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MUSOG
(ifwcll field,one lat/lon.-is sufficient)
22-Certification:
9 \
6.ls(are)thewetl(s): IJPermanent or ❑Temporay S:C , CentnecWellComzror Date
Er s£gnin�this form.l hereln.-r e rift that the,:ril(s)Iva.,0wre)constructed in crcordonce:rich
7.Is this a repair to an existing well; GYes or n—No 15.1 NCrC 02C.070n or 75.4 NC.£C 02C.0200 deft CoaTtwelion Standards and that a corn
lfrhis it a repair,fill out knonr wall rnnSlrtrctiat information and Prn/at rhr nu vrr nJ'the nrrirhs record haT been provided to the+.rll owner.
repair raider'_31 rrnrarks sSrV0n or on the back orthts form.
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 page to provide additional well construction info
construction.only 1 GW-i is needed. Indicate TOTAL NUMBER of Wells (add'See Ovee iu Remarks Box).You may also attach additional pages if necessary.
drilled:.
24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 51 (fL)
for mutdple nr11s'is'tiff d6P&y£fdtffcwnt(trample-3(c200'«net 3(a1100j Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing:40 (fr 24a. For_ail Wells: Original form to Division of Water Resources (DWR),
!f hitter teed is ubore casing,use'-+- ) Information Processing Utut,1617 MSC,Raleigh.ATC 27699-1617
11.Borehole diameter:6 1/8 ( -) 24b.For Injection Wells:Cony to DWR Undergotmd Injection Control(IUC)
Atr RotaryProgram,t636 MSC,Raleigh,INC 27699-1636
i..Well construction method. 24c.For Water SnpDly and❑Den-Loop Geothermal Return Wells-Copy to the
(i.e.auger,rotary.cable-direct push.etc.)
county ennronmental health department of the county u•6ere in.,-talled
FOR WATER SUPPLY WELLS ONLY:
n 24d.For Water Wells Dr odncino Deer I00 pOp GPD Copy to DWR,CCPCUA
13a.Yield(gpm) PcTmit
Air Li of Method of test: ft PrograTn•1611 MSC,Ralzrgh,? C 27699 16 t I
13b.Disinfection ty Chlor. Tabs 1 1/2 Lbs
pe: Amount-
Form GW-1 !North Carolina D panmcnt of En,irourricntal Quality-Division of water Ri ourccc
Rc,,iscd 6-6-201 x