GW1-2022-07277_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only'
1.Well Contractor Information:
{
Alfred Kiesling Sr
Well Contractor Name FR TO DESC`.JMON
2670-A m.
NC Well Contractor Certification Number fL �l /Z/ •V
B & K Well Drilling Inc FRaAl TO DIAMETER MATERLkL
Company Name 0 ft- It3� ft• 6114 in- SDR-21 PVC
2.Well Construction Permit":_ FROM TO UTAN!TER TMICKNe-N, MATERIAL
Litt all applicable well co»smlcGar permtts r.c.OTC.Corury . . ft. in.
3.Well Use(check well use): ft. fL in-
Water Supply Well: ".t:7_SC3tt.
OAgricultutal ❑Municipal/Public FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in
OGeotherrnal(HeatimVCooling Supply) 2<dential Watel'Supply(single)
ft- fL is
Oindustrial/Conlntercial OResidential Water Supply(shared)
zti$sitiRO UT:::; <r<:><:.;..;>:>::
Imgation ❑w'ells>lUO.OW GPD FROM TU INUTERIAL ENIFLACEMENT METHOD&.,L.NIOUNT '
Nun-Water Supply Well: 0 fL 20 fL RAntonit,-
POUr
0Monitoring ORc occry
fL ft.
In
j
e
c
t
': _el:
❑A wRRecha barge Croundwater Remediation Ct fr.
OA (uferStory eattdRecov i4:&41lflY�83Y1f'4f3ffi te}._:..:,,.:;:::,::,.,;;.:;,;;;•:; ;;:;;is.:q b' ety OSahlli[v$artier FROM TO MATERIAL EINVLACEMENT METHOD
CAquifer Test OStorri water Drainaee ft. ft.
❑Experimental Technology OSubsidence Control rL {(
❑Geothermal(Closed Loop) OTracer
:2tk:8Rl1Ui)�H6� 'gtacli'a4�YieA�; ;if�tes�atir::;>:%:<:'::>:>i�:�:::::<�;i< >:•:<:::
CGeotbermal(Heatino/Coolins Return) ❑Other(e.+tplain under#21 Remarks) FROM To DESCRIPTION(cntor.hardness sLn/ nta K�I
ft. ft. � L` �
4.Date Well(s)Completid,�' �yell ID# fr. ft.
Sa.Well Location:_ ft. O ft.
ft. ft.
Facillily/Owmer/Name FacilitvMW(if appiicable; ft. fL
414
Physical Address_TCity.and Zip fr. fL
RRTi'S::`>: :`iii3i''c;.
County Pa=cllde ificatianNo.(PLN) AUG 0 9 2022
Sb.Latitude and longitude in degrees/minatesiseconds or decimal degrees: n.
(ifw•cll ticld,one Iat/lon.o is sufficicnt) SW
22.Cc n:
6.Is(are)the well(s): !]Permanent or OTemporary parure Certified Welt ornractor Date
Er sienin�tkir 16tm.1 hereh r e till ri or ri a+:rll(sl+Kes(tee r)constructed in arcordance::•ith
7.Is this a repair to an existing well: G Yes or nNo 1..4 NC4C 0_rC.0100 or/S.4 A'G1C 02C.0200 IrkU Corcttruction Standards and that a com
!j this it a repair.fill our knonn well r»nstnrcrNon informarinn and ern/oi-the nomre of rite of this rrcnrd has bren provided to the..r//'o,mrr.
repair under*21 remarks suction or on the back of&rs form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hating the same You may use the back of this page to provide additional well consuuction info
construction.only i GW-I is nccdcd. Indicate TOTAL NZIMBER of wells (add'See Chet'in Remarks Box).You may also attach additional pages if necessary.
drilled: j
G 24.SUBMITTAL INSTRUCTIONS
9.Totsl well depth below land surface:_ o� (am)
For atulrfple+tr//s list all depdn•if(8fferent(acromple-3(c100'and 2(a!1001 Submit this GW-t within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For A J Wells: Original form to Division of Water Resources (DWR),
11+'oer level is ubu+•e casing. se"+ (ft') Information Processing Unit,1617 MSC.Raleigh.NrC 27699-1617
il.Borehole diameter:6 1/8 (in-) 24b.For Injection Wells:Copy to DWI-Underground Injection Control(rUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
(i.e.auger,rotary.cable.direct push.etc.) 24c.For Water Snpp and Open-Loop Geothermal Return Wells:Copy to the
county environmental health depattment of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water We1Rs producine over 1Q0 000 GPD Copy to DA'R,CCPCUA
13a.Yield(gpm) �� Air Lift Permit Program,1611 MSC,Raletgh.lvC 27699-161 l
Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 LbS
Form GW) North Carolina Dg.artmcnt of En,iroamcnta!�F' Quality-Division of W'arcr Rc�ourccs Ravis�d 1-F-30Ix