GW1-2022-09846_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only-
1-Well Contractor Information:
Alfred Kiesling Sr
Well Contractor Name FROM TO DE50RIP3T0N
2670-A rt. ft_ OA-,
NCI ell Contractor Certification Number O e �j e
B & K Well Drilling Inc F: t TO :..9 :t>
FROnI DIAyiETfitk THICI:NFSS lY1ATHRL�I. �
Company Name 10 f- I ,TQ ft- 6 1/4 in SDR-21 JPVC
�1 q/ `t4CiTi.O'...::>i:'•::::.;`'•^;';:i::?:.`;>:`%.f? ':2Y'.`':
2.Well Construction Permit I :ROM I TO DIAVI TER THMKtiYSS MATERIAL
Lit;all applicable we11 courrucdon permits .e.L1C.(:ouniry Sato.6cdancc:fire•.) ft. I fL
3.Well Use(check well use): fL i ft. in
-
Water Supply Well:
FRONT I TO DIAMETE THtCNF$$❑ t ulttua! fr. I fL ix SLOTSIZE IC MATERIAL
n.
• '� OMunicipal/Public
❑Geothermal(Iieadn_iCooling Supply) a<dential Water-Supply(single)
❑Industrial/Commtercial tt_ I rL h>
ORtsidential Waxer Supply(shared) :.;: .,
❑Irrigation M,8AZ�=,
. ....................... ...: .. .:. ..:.::...:.:::.:..::...:::. •.::.:
❑Wells>100,OOO GPD X%TERTAL E-tPLAC dLNT W HOD&A,%fowr
Nun-Water Supply well: Bentonite Pour
❑N•lonitoring ORcc:ovcry'Injection ReILr.
❑AquiferRecharge ❑Groundwater Rertuediation ...::.:..:, .:. ):'iE 'kf %:':i:,'•'::i_: i .i:cy:i C?::`i:.;i;r'i:; i::::a:
OA__ui&r Storage and Recovery OSalfii ty Barrier
...........
FFt(Inl TU MATERAAl. EMPL�CEI1IflYTMETH(10
CAquiferTest OStormwater Draineze fc fr_
OExperimental Technology ❑Subsidence Control
fc ft.
OGeothettnal(Closed Loop) ❑Tracer
.
��Sti'a�ctfaieiic3:;33F:i�e2:�:>''%`:;:">::
❑Geothermal(HeadWCoolime Return) ❑Other'(explain under=21 Remarks) FRO"' TO DESCRIPTto'S(color.hardness
rl' fL F ft. �+�� O�
4.Date Well(s)CompletW--A�_�Well ID# ft. ft. t d C
5a.Well Location. ft. Q fL
Fa tltty/(hWterNatne FacilitYM#(ifapplieablel ft. fL
tacisn v l Z fr.
Phyaeael Address.City.and Zip fr.
fr-
�3-/O a 71s6 :..
County- Pa__el Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifw•cH field,one 1a69oc.is sutficicat)
22_Certific lion �
6.Is(are)the well(s): !lPenmanent or ❑Temporary S_=zt ofcdniffied Well Cottaactor Daze
drr.'gaing rrs/oia:.!he in.rcmiF:neat the i:rll(V fiats(ware)consirucred:a arcordmive i:irh
7.IS this a repair to an existing well- ryes or n-o 15.4.,CJC O'C.0100 or 15.,'`C:1C 12C.0200 W-e1f Corcctract.on Standards and that a cam
Ij rhls rs a repair fell nor knoi,r well t-onstruclion info rrafnn and erolain the ran d of r.�r -If rrfic rrenrd has ben7prmided ra the xrll of err.
repair rends:21 remarks section or on the back of Nrr-c 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-1 is needed. Indicate TOTAL NUMBER of Wells (add'See Ovee in Remarks Box).You may also attach additional pages ifnexessary.
drilied: 1
? 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For mu(riplr nLlls lisr all Jepily if&jfsrem(arample-3(�00'aael20 001 ( ) Submit this GW-1 within 30 days of well completion per the following:
10-Static water level below top of casing:40 (ft) 24a. For All Wells: Original *form to Division of Water Resources (DWR),
if varer lewl is ahoi-e casing,u>e•.+-' Information Processing Unit,1617 MSC.Ralei_h.NC 27699-1617
11-Borehole diameter_6118 (in-) 24b.For Iniection Wells:Cony to DWR Underground Injection Control(IUC)
12_Well construction method:
Air Rotary Pro°g am,1636 MSC,Raleigh,NTC 27699-1636
(i.e.augar,rotary.cable.direct push.etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the;
county ennron dental health department of the county where imstalled
FOR WATER SIIPPLY WELLS ONLY:
24d.For Water Wells producing over 100 000 GPD-Copy to DNR,CCPCUA
13a.Yield(gpm) Method of test-AI r Lift Permit a o_ N
mr,1611 MSC.Raleigh. C 27699-16I 1
13b.DisinfecRon type: Chlor, Tabs Amount: IZ Lbs
Farm GW-1 Noah Carolina Dcpanmcnt of Bn.ironmcntal Quality-Division of Ware-Rcsou=cc
Revised 6-6-201 K