GW1-2022-09845_Well Construction - GW1_20221028

WELL CONSTRUCTTON RECORD(GW-D For Intenal Use Only-
I.Well Contractor Information:
Alfred Kiesling Sr
Well Contactor Naar FitOh[ TO 1 DC:RiPT(O�
2670-A i © `r i//�./ S fr. '1444
NC Nell Contractor Cemfimtion Number
oyX:E�'FE1Z:.�'�nF4'c[ rit��'8asi:3'seEa';':?rj1� ER• /:>..... ...:.;;:..;v i'.yy:;::::
B & K Well Drilling Inc meant T'i I Duud lam I T,i M'i' MAT>�,�
Company Name 10 fr I fL 16 1/4 la SDR 21 JPVC
c
2.Well Constriction Permit _ 13��Y FROM I To I DIA.%1ETER I TIi1CKN(SS I MATERIAL
Lis;ill applicable ml/con5mfction prrmtLs .r.u!C Corvrry.Suet.Ma'iaucc•.ex.) I fL 'i ft
3.WeR Use(check well use)-- fr. i ft I in_
Water Supply Well: i 275SQ [+,�ii: :;::::<Y-'..'� [;'::'>':::;>' :.#;:'?:•::»:;i>::r:':::;:;;i` :.� 't:'::»:::'::?;:>:::;
❑ t;DltU ❑vi
fal FROM I TO DIAMETER _CLOT S37F TMtCKNFSS M..ITEWAC
unicipaltPublic ft. i ft. I in.
❑Geothermal(Ileaaneicooling Supply) 21<dential Water Supply(sillglei ft I fy i is I �
❑]ndusrtial!Conituercial OResidcntial Watt.Supply(shared)
lmeatlon ❑Wells>100,000GPD FRont ro x1TEar�x >:s nc .>ENrl+t raoa&.iratrrr
Nun-WaterSnppty Well: Q ft 20 �- Bentonite Pour
❑Monitoring 7R�o�cry
Injection W e1L- ft I fr_
❑A uifet Recharge ft fr_
q ❑Groundwater Ratnediatioa
❑A4�far�O�;a and Recovery GSaltTiryBaina >>F£+3t:o:Sh k:3'fisc-TaE.R.:I.:A.L:.. >:'-FJtF:Y%<T MO t O
CAquife•Test ❑Storarw'ater Drainaee ft fr
❑Experimental Technology ❑Subsidence Control It
OGeothermai(Closed Loop) OTraoe- 1
:•�=8RE1rL;itlT�:��:atrxAa :�eEalif25`
❑Geotbamal(teariae!Coolin--Rearm) :]Other(e..Viain under=21 Remarks) I FROM To I DESCRTMON'(mbr. ."'Mk` .Amer.)
t/ ft I I Tft. _.0 0/il
4.Date Well(s)Completed, a Z Z well TD#
5a.Well Location:. ft �� ft L � f M4'x
ft
Facilityl0w,rerName racilitvn;(ifappi;cable) ft J fC i )"�"ell,j r
'g /Y�l e3= � �t/`_r hi- l�lJ� � T fr. � ft C U
Physical Address,City.and Zip fr- 0(`
n 1
I
6� �a
Uri
Couetr 1'a.=c1 Idcruifuion Na.MN) r�fr.�,.,�;,•.u•:� .r
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5b_LaTiatde and longitude is den ees/minates!seconds or decimal degrees:
Of-CH ticld,one taa'lorw is qufficicrrt)
��C.ertifi 'vn:
A}Q�
6.Is(are)the well(s)- Permanent or ❑Temporary' 3_�r of Cciaed Well Cotmcor Dare l
3r s:;�nrn5:cis lain.1 hnrei*renff:rhar the.:rll(sl%.as(r.rre)consrruoed in accordm:re:drrr
7.Is this a repair to an existing well; _Yes or jU:-VC:C 03C.Wor XCAC,32C-0200 Meff Coa uceon Stardmds and r!krt a com
1P)is is a rrpafr-fill aw lwo>,r and exp!air:itr na;rre?i C4? of this mce rd has bcrnrreridcd ra rho rrll o-rm
repair rmder'21 rgnwria secnon or on the back orrTiis fa m.
23-Site diagam or additional well dehaiLs:
8.For Geoprobe/BPT or Closed-Loop GeorhermaL Wells having the same You may use the back of this page to provide additional well construction info
construction_only 1 GW 1 is nc eded. Indieare TOTAL N7LTMBER ofweils (add'See aer in Remarks Box).You may also mtach additional pages ifnecessary.
dried: I
24.SUBMFITAL INSTRLCTIO-S
9,Total welldepth below lead surface: 7�S
Far multfplr ut!/ls list all deptks lfdfjfrren:(�rmrtple-3(c?_=00'and 3(d+J00) (f) Submit this GW-1 within.30 days of well completion per the following:
10.Static water level below top of casing:4O (it.) 2 fa- For Au Wells: Orignal Arm to Divisioa of Water Resources (DA'R),
!f,rater lest!is abc a casag ux-+" Ia._ormadon Processing;snit,1617 MSC.RaleizlL NC 27699-1617
11-Borehole diameter-6 1/8 (try) 24b.For Injection Wells:Copy to DWZt Underground Injection Control(IUC).
12.Well construction method:Air Rotary Prograat,1636 MSC,RaleighL NC 27699-1636
(i.e.auger;rotary.cable_direct pmh,err.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the.
county®N,ronmental health department ofthe crormry where lastalled
FOR WATER SUPPLY WELLS oN-Ly:
24d.For Water Wells Prod
ncin>r over I00,000 GPD:Copy to DN'R,CCPCI;A
L3a Yield m Air Lift Permit Program.1611 L1SC,Raleigh.NiC 27699-1611
(gP ) Method of test
13b.Disinfection type: Chlor. Tabs Amount 1 1/2 Lbs
Form GW-1 NOrih Czrolira flcpatrmcnr of En.ironu=ral Quality-Division r_"LirarC RG'O,ecs Kcviscd b-1+-3019