GW1-2022-07304_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1} For Lltemal Use Only':
1.Well Contractor Information:
Alfred Kiesling Sr 14.NS
FR N TO DE'�'C'RiPTtO\
Well Contractor No OLl h. G Q Q
2670-A ft_ jigVV fir. )l4l,4 p( S
NC Well Contractor Cetrification Number B & K Well Drilling Inc FROM TO DIAMETER THICIGNESS MATERLAL
0 ft• Is' ft- 6 114 SDR-21 PVC
Company Name tt : ER'G§iFl\1�'t#� 3SEaI final'
I t�ZO�i i 7'0 UtAMEfEK 77i1CKhE55 MATEKI\L
2.Well Construction Permit#:
ft.
List all applicable well c0larrucd0n pern-iis fix.LUC.Corarrv.Stole.7•an"Olfcc.etc-)
ft. CL In-
3.Well Use(check well use): l.: '.
Water.Supply Well: FROM TO DIAMETER CLOT SIZE THICKh£5$ MATEKIAL
❑. cultura! ❑municipal/Public fr. ft in.
OGeothermal(HeatinsiC•oolilla Supply) 2<lidential Water Supply(single] ft- rL in.
Water Supply(shared)L)❑]ndustrial/Conmrercial ❑ResidCnnal
i;'l�r�iltf3�1..:: <;
❑Irrigation
❑Wells>100,000 GPD FROM TU >L\TERL'1L EhtPLACEM&NT METHOD&L\IUUS�T
Nun-Water Supply Well:
p tL 20 fL Bentonite Pour
❑monitoring ORccoccry R, ft.
Injection Well: ft• tr-
ou dwater Remediation _. ....... ..:.. ..: >:;::•.::.::.,
❑Aquifer Recharge OGr n a>s<';:>::<;
❑Aquifer Storage and Recovery ❑Saliuiry Barrier FROM TO FIATF.RIAL EMPLACEMENT METHOD
CAquifer Test OStormwater Drainage
i
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer attai Aaddiiianeli€saeaisix??><:
FROM TO D iPTiOh(wtar.bardnesstspOltrock erzinsnte etc)
❑Geothermal(Heatine(Coolins Return) ❑Other(explain under=21 Remarks) ic, 0 ft.
4.Date WeD(s)Completed-
ZZ Well ID# tt• ft.
ft. fit.
Sa.Well Location:
.�
Facility (ifz licable; fr. R
Facility/Owner Name GF
ft.
f. Intc-r"R3w n Flrzx.3ccK'ng Unit
Physical.Address,City.ar Zip
('ounn. Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-ell Held,one latrlona is sufficient) WCertOfffic in•6_Is(are)the well(s): Permanent or ,Temporary' ledWellCon a or bate
Zr sigmng ri�Lc form.I herei•.rtattfi�that the,&II(s).va!r(tvereJ<-onstrue•red in arcordanve::irh
7.Is this a repair to an existing well: ❑Yes or nNo S.a N-CAC Ok.0100 or 15.;NC.4C 92C.A20n Well Co¢rtruction Standards and that a gain
1)this is a repair.TI/nut knov,r.well<»nctnrcr;rne infortrarinn and ern!air,the raver nl tit^
njthis rr•enrd has bretr provided to the­110 7mr.
repair rnrder#21 remarks section or on the back arthis.orm. 23-Site diagram or additional well details:
S.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 i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'inRemarks Box You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCDONS
9.Total well depth below land surface: -� (ft.) Submit this GW-1 within 30 days of well completion per the following:
fur muhipie uri/s list rrll depdLy if eliffe-r-ent(eromple-3kg000 and 2(d!i 001
24a. For AJJ Wells: Original form to Division of Water Resources (DW'R),
10.Static water level below top of casing:40 (ft.) information Processing Unit,1617 MSC.Raleigh.NC 27699-1617
!l muter level is ubure easing,else
6 1/8 24b.For Injection WeDs:Copy to DWR Underground Injection Control(IUC)
11-Borehole diameter: (lo•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
Air Rotary24c.For Water Supply and opeo-Loop Geothermal Return Wells.Copy to the
(i.e.auger,rotary.cable.direct push,etc.) county environmental health department of the county wfie re tn.talled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells ptodncina over 100.000 GPD:Copy to DWR,CCPCL'A
— -
Air Lift Permit Prom,16l t MSC,Ralagh,N L 27699 161 I
13a.Yield(gpm) Method of test:
Tabs - 1 1/2 Lbs
13b.Disinfection type: Chlor. .Amount.
t
Form GW-I North Carolina Department of En,iroomcnral Qualiry-Division of Watcr Rcso`urccs Revised 6.6-2019