GW1-2022-09850_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1) For internal use Only-:
I.Well Contractor Information:
Alfred Kiesling Sr
. ... ..............:,............
wel!Courraaor Name F720A( TO DECCRIPTIO\
2670-A tt DVft. `; p
NC Well Contractor Cerrification Number 7 f` C. Jl47 0�7
B & K Well Drilling Inc . N.
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FROM TO DL&M''TER 72
tCKNESS 1-MATERIAL
Company Name
ft. SoZft 6 1/4 in. ISDR-21 JPVJ
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2.Well Construction Permit R:11 P- t3.2 �O oL eRou I TO DIAMETER 7xtCKnE55 MATERI:IL
LLrr all applicable well c'OA.strurflott penaiLT .e.U1C Corarrv.State.Variance.etc.) ft. j ft,
3.Well Use(check well use): ft_ fr, in-
Water
eupply Well:
: 1
Wat srCi3
Sc Erzs>`:a<:>i::>::>::;: :>::^`::;:a::�'�»: :>;;s<:r:<;�:>>•::;::?c:«<?;;:;:::cep:>sz:>:»::<.>s,..: .; .
FItOAt TO DIAMETER SLOT SIZE TRICK1iF5$ MATERIAL
❑Agricultural ❑Mtmicipal/Publi(: ft. ft in.
OGeothelmal(fieatingiCooling Supply) 2<dential Watts-Supply(single) R. fL i-
Olndusrrial!Commercial ❑Residential Water Supply(Shared)
❑irrigation ❑Wei Is>100,000 GPD FROM To E161PLACENMNT METHOD&.11fOUWi
Non-Water Supply Well: 0 f` 120 Bentonite Pour
❑NIDnitoring ❑R=ovcry• ft_ n_
Injection Well:
❑A uifer Recharge tc fr_
q - ❑Grouudwater Re-mediation
ife OA ur Storage and Recovery .. ....�......... ..............q �' �' ❑.Sa1i111LV$a771Cr FRO1I TO MATERIAL F,MP44CEM1IFM METHOD
❑AquiferTect ❑StormwarerDrainage fc ft_
❑Experimental Technology ❑Subsidence Control fc ft.
❑Geothermal(Closed Loop) ❑Trager
❑Geothermal(HeatinJCooling Return) ❑Other(explain under=21 Remarks) FROM To DESCRIPTro\(color.hard s H/rockry arm site.a.)
gCO f
4.Date Well(s)Completed^ .20 _Nell IT3# ft. Q ft. �Q/�fj G l�' /J�j'
5aa_-W1ell LocatiOD:- ,) O ft. 9 IL /v /1 f
ff. !f—
Factlr /OvTerNarrK tY" ft. fL Facility TT);(ifapplicablel
Physical Address.City.and Zip ft. fe
OCT 9 9
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County Pared ldcntification No.(P1N) In9Urv'(�c:F„'�^,Sl 11�fpGsq;•;:i,�1 '1 a
Sb_Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat'lona k sutFcicno 22U
6.Is(are)the well(s): lKermauent or ❑Temporary on or pa
Brsigning thislornr•I herel r rerrifr rhar the rsrll(s)+vas(there)construt•ted in accrrdanre ikh
7.Is this a repair to an existing well ❑Yes or nNo I U:VC4C 02C.01011 or d4 NGlC 02C.0200 ti ell Cotctaucrion Standards and that a com•
If rhis is a repair.fill our kno>7.,well canvntction infonnarina and ern/ai-,the narur"a%rt:e of this record ha-a hcrnprm-fded to rho xr/1 owner.
repair rnrdtr t21 remarks suffon or on the back ofthiF form.
23_Site diagram or additional well details:
8.For Geoprobe/DFI or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.(mlv I GW-I is needed. Indicate TOTAL NUMBER ofwclls (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
atiuea: j
(� _ 24_SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple%mlls list all depilny if($Jferenr(anmple.-3(ar_00'anrf2@100) (ft) 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 Ail Wells: Original. form to Division of Water Resources (DWR),
If water level is above casing-ash••+ Information Processing Unit,1617 MSC.Raleigh_NC 27699-1617
11_Borehole diameter: 6 1/8 (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(rUC)
Program,1636 MSC,Raleigh,WC 27699-1636
12_Well construction method:Air Rotary
(i.e.auger.,ro rary.cable.direct push,etc.) 24c_For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
6
county ennronmeatal health department of the cotmry Rhlere installed
FOR WATER SUPPLY WELLS ONLY: 2.1d.For Water WeRs producing over 100,000 GPD-Copy to Dti'R,CCPCUA
13a.Yield(gP m) Method of test:
Air Lift Permit Pr "ram.1611 MSC-Raleigh. 2727699-1611
•� 1.�
13b_Disinfection type: ChlOr. Tabs Amount: 1 1 I2 LbS
Form GW-f North Carolina fxTarrment of Enviroamcnral Quality-Division of Water Resources Reviscd 6-6-201 x