GW1-2022-09844_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1) For hiternal Use Only:
1.Well Contractor Information:
Alfred Kiesling Sr
.... ...:...............
Well Contrac[or Name FROM TO DESC'RtPTTOV
2670-A 15 o at-Fs
NC Well Contractor Certification Number
B & K Well Drilling Inc ::. d l
FROM TO DLAvtErER 7ffiCtCktSS KATERLAL
Company Name 419 0 fr. 3 fL 6 1/4 1° SDR-21 JPVC
`
2.Well Construction Permit 1: /J 7 2� FROM TO DIA_Arb-r$R I THICKNESS I MATERIAL
Lis:all applicable well coastnsctian prrmrtt r.e.WC.Caaarn.Sate.VaHanec.arc•.) Ct. i ft- in.
i
3.We0 Use(check well use): ft- I fL is
1
Water
e Supply Well: �:fi7�S!'�E:^�>:;:: ::?: i:::�c?;�: :::i;>>::i>:.::::;%•sitf5:•`:: sic::;:;'z>;�:<iS::i;; Gs;:%a;:
❑4griwltura! FROM TO I -"--FR SLOTSIZE THICKNESS MATERIAL
❑municipal/Public [t. I fL I n>_
0GeotheM12)(FleafinsiCooling Supply) a<dential Water-Supply(Singlei
ft. fL ht
❑lndustrialtCorutnercial ❑Residential Water Supply(shared)
<ilGfif313 S:'
❑Irriga o i[ n ❑W I C Is i UU.000 GPD ;rl:ont TO :....•�.:KXIEft7AL: ..ENIPLACT<'VTEN7 MELHUD&.i1f0[RJT '
Nun-Water Supply Well: Q tL 2 fL Bentonite Pour
❑Alonitoring ❑R«oc cry
tt_
Injection Well: ft.
❑A uifer Recharge ft. fr_
q ❑Groundwater Ramediatioa
❑ uiferStora e ==:3 :&41iIR3.YL4E3:Ef..:..,..,o k}<;»:::s':'<.<<::=??s?::•;:;.::z>•°•:»->:< •>:::::•v?<. :>::::>`:?:
Aq g and Recovery ❑Salntity Barrier '
. .............. ..............
FRUAI TU E4ITERIAL EMPLACEMENT METHOD
❑AquifeaTect ❑Stormw'ate:rDrainage iL fL
❑ExpeHrneirml Technology ❑Subsidence Control Cc fL
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating(Cooling Retum) ❑Other(explain under=21 Reurari c) t To DFscRlrrto�(mwr haadtiess zar aim,size.v�I
4.Date Well(s)Completed O p2 Z Z_yyell # Q it. lift l/r I!_ C.
Sa.Well Location: fL Zft r G!i c✓
Q 7ZIC S fC.
Fac.+IrtylORrcrNarrK 1 r— E_
2cilityTn>'(ifapplicable; ft. fL �"_'j;-_•.
Physical Address,City.and Zip ft. O f A [`
�•r�l-mil.
County PaMcl Identiflearion No.(P1N) FI"11411 ti„D1�ii
v aQf
Sb.Latitude and longitude in degrees/minatesiseconds or decimal degrees: „
(if yell field,one Wong is sufticicnt) �
21 Certificati :
6.ls(are)the well(s): nPermaneut or OTemporary Si—- CatiSed w oaractor Date
L-signing M fornr.1 here8r renfli,rhar me+:rll(s)was(were)consavned in at cvrdartee lade
7.Is this a repair to an esisting well: 0-Yes or nNo 1+,4:VC.C 02C.Mr or 15.4 rVGIC 02C.0200 Aral Cort®vcthm Standards and rhar a cm,
If rhis is a repair fill our knee well canstrttcn'cna infoarrminn and emlai.me nxvrr of the ofrhis meord has brca prmided ro the r-r11 one,.
repair under 21 remarks sedan or on the back orNrrs fama-
23.Site diagram or additional well details:
9-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-1 is needod. Indicate TOTAL NUMBER ofwells (add'See Ovee in Remarks Box).You may also attach additional pages ifnecessary.
drtlIed:_
t,�f 24_SUBMITTAL INSTRUMONS
9.Total well depth below land surface: 7!0
For multip n le rlls list all deptly ffdifferenr(examples-3(a100'ant(3(ati001 ( ) Submit this GW-1 w'ithiti 30 days of well completion per the following:
10.Static water level below top of e7.s n- 40 24a For AlI Wells: Original form to Division of Water Resources (DWR),
1f+ruler level is abw•e rnsing,we"+" (ft.) Information processing Unit•1617 MSC,Raleigb-NC 27699-1617
11.Borehole diameter- 6 1/8 (in-) 24b.For Injection Wells:Cony to DWR Undergrotrad Injection Control(IUC)
12.Well construction method:
�
Air Rotary P'o. ma 1636 MSC,Raleigh,NC 27699-1636
(i.e.anger:mmry.cable,direct push,erc.) 24e For Water Supply sad Open Loop Geothermal Return Wells Copy to the
county emnrortmessral health depattnxeat of the county ufiar instal![d
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100 000 GPD•Copy to DH'R,CCPCUA
13a.Yield(Bp-) Mehd of test.Air Lift Pcn m Rv
ntt Progra ,1611 MSC.Raleigh. 0 27699-1611
to .1 t�
13b.Disinfection type: Chlor• Tabs Amount- 1 f/2 LUS
Form GW-f North Carolina Department of En.iroamental Quality-Division of ware Kc ou ccc
Revised 6r6-201 x