GW1-2022-09860_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For!nternal Use only:
I.Well Contractor Informatice:
Alfred Kiesling Sr
Well Courmaor Names FROM I TO I DESCRIFI TION
2670-A i 1" (T41', ,1L Ze
NC Well Contractor Certification Number
B & K Well Drilling inc :<�:.: �: ��: � ��: ':�>�� = ::: :... ;:• ::'
FROn[ TO DLA-METER I THICKNESS I rdATERL.%L
Company Name 0 ft• 6 1/4 in- SDR-21 JPVC
n�/ A tJ#h�'F3SE�T�:
2.Well Constriction Permit R:—C� /lCi® V I Boat I TO DiA\IETER THICKNMq I MATERIAL
r
List all app/iea7ile xerll eorrsmleGon prrmits .e.GIC.Corur{v.State.FarimrCe.ercJ f[. ft_ in.
i
3.Well Use(check well use): ft. ! fL in.
I 1
Water Supply - . : :: ' : >:;>:Well: .>:.••a.,::....:'
Fl20At I TO DIAMETER SLOT SIZE THICKNFSS MATERIAL
❑. Cultural ft. I ft. I[L
� ❑Municipal/Public
❑Geothermal(Heatips1/Cooling Supply) 2<dential Watm Supply(Single) ft. I ft. in.
❑Induspial!Conutrelrizl OResidentialWatdrSapply(Shared)
Lt.X3t
❑lrngation ❑W"dlls>tU0,000 GPD FROM TO JL12ERIAL ENIPLACEKENT METHOD&.1010UNT
Nun-Water Supply Well: (0) fL 20 fL 1 gentonite Pour
❑:Monitoring ❑Raovcry
fr. fc.
Injection Well:
❑A uifer Recharge fL ft.
9 ❑Groundwater Remediation
..
OAgtrifdr Storage and Recovery OSaIiI 4A iGR3y ....'q1'�4{ :atik1? ':::<" < ' <%%z: >r>=....:c' :^<?;;::;E'??: `%L:
�' liCv Ba77tdt FROM TO rVLTERIAL F.MPL�LCEMENT METHOD
-
❑Aquifer Test ❑Stormwater Drainace iL ft-
❑Experimental Technology ❑Subsidence Control IL fr.
❑Geothermal(Closed Loop) OTracer
:#�7,�?�i�hihT�� 'aitic6 aieiii ;�iiecesaaiaih> ?%?z`:?z>r.': :ia�:: ;•�?: :.:':;
❑Geotbennal(HeatinJCoolins Return) OOther(exttlain under=21 Remarks) FRont TO DESCRIPTION[color.herd reek �,i:...C.l
Q �n1��, Q fL J ft. t;`/n
4.Date Well(s)Completed- / o.W,2— - eu ID# ft. /v fr. ,�✓D�
5 Weli Location:- R. �n fr t
FacilityloAmerName I Facility M#6fapplicable) ft. /, fL
t$ •Y (�nil L4J�L4 -
ft. I K fit.
Physical Address.City.and Zip • '-' ft' �'. !m,ram _"F,< r!^�_
COS Pa.=c1 Identification No.(PIN) a
L
9b_Latitude and lonaaitude in decrees/minatesiseconeis or decimal degrees:
(if well field,one Iat/rong is sufficient) flq+C;�fD 1 ter ��q�??_Certification: rr�� �UTiis
✓i�iti�f� r,..,
6.Is(are)the well(s): rJPertnanent or ❑Temporary S_=2 u Ceria d Well Consec or pate
?r r.'gning tAslbrn:,f F.ereiT rertif:rhar the+:Pll(s)teas(lwre)construeTed:n accordmx•e t.irlr
7.Is this a repair to an misting well: Yes or •]No 5.4:,C 1C 02C.777r cr i5.; "C JC 72C.nzon TV67 Corutrun.on srattdards and that a coin
p'this fr a repair,fr(1 nu;barn well('01wrna-don infbMa inn and ern?air.the ra:ure n;7he of this rrcnrd h¢s Ixcnprcridrd to the xrll of err.
repair rnrder Z1 rema,kr soon or on the back ofr)ric form.
8.For Geoprobe/DPT or Closed-Loop Geoth 23.Site diagram or additional well details:
Geothermal Wells hating the same You may use the back of this page to provide additional well construction info
construction.only i GW-1 i;needed. Indicate TOTAL NUMBER of wells (add'See Ovee iu Remarks Box).You may also attach additional pages if necessary.
drilled:_ f
2 24.SUBMITTAL INSTRUCTIONS
9.Total�ceII depth below land surface:`V�•S
For•multiple arils firr all depilrs ifdfffrrrnt(example-3(cr_rr'«nd?(d irr� ( ) Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
ff,rarer level rs m
above casing. e`+ Information Processing unit,1617 MSC.Raleigh-NC 27699-1617
11.Borehole diameter-6 118 (�- 24b.For Injection Wells:Copy to DWR_Unde
rground Injection Control(II)C)
12.Well construction method:
Air Rotary Pro-��1636 MSC,Raleigh.NC 27699-1636
(i.e.auger,rotary.cable.direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
county en-Ironmenral health department of the county wbe re installed
FOR WATER SUPPLY WELLS ONLY:
^ 24d.For Water Wells prodncina over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) tl + Method of test•Air Lift 'Permit Program,1611 MSC,Raleigh.NC 27699 1611
13b.Disinfection ripe: Chlor. Tabs Amount: 1/2 Lbs
Form Gw-f North Carolina DLTarrmcnt of En.ironmcaral Quahry-Division of waTez,Reso ace
Revised(r!+-?pl>t