GW1-2022-09862_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1) Fa L+rrenal use Gnly-
L Well Contractor Information:
Alfred Kiesling Sr .; ,.. ... ... ...
:..
WtllCo»rraetorName FRONT TO DE(•CWP17O\
2670-A
NC Well Contractor Cenincatan Number
00 fL Y/
L' sY�'.FE$: '$�ifir.:,..��'ra's"eiF'siih':fi$3f1LPQE'�.'tif''::.:... ,�:;:(:[:�S;i:�rii•:ii'`:iii B & K Well Drilling Inc FROA1 Tn TER THICIiNE55 MATERL�I
Company Vame 0 ft. I /�ft 6 1/4 in- SDR-21 PVC
a b 9
2.Well Construction Permit m: I•-ROn[ TO
DtA}1E'TER THtCK)rFS$ M11A'rER1AL fir,r11 appY,•cable xt•1!c0nsmtction perm_.ts .e.I11C.Lomrn•.Suite.Y'an."note,erc•.j ft. I fL is
3.Well Use(check well use): fL I fr-
in
Water Supply Well: ':Z7SG3F�€fitEi>iE::<i:?.>:::<??i:^..r.+:;:;';••::i"i;: :; .
❑A cultural El20M1i TO l DIAMETER CLOT SIZE THICKIVE$S !NATF.R[AL
-- OlvlunicipallPublic ft. fL I in.
❑Geothermal(HearinviCooling Supply) a4idential Wags Supply(single)
OjndustriaLlCornmercial fr_ fL itL
❑Residential Water Supply(Shared)
❑Irrigation ❑1Vells>100.00UGPD 1LIIERIAL E�IPLAC>•<_vn?t�'r MECBOA 6..1VUUVT Nun-Water Supply Well: O fL 2Q fL Behtonite Pour
ON-fonitoring ORccoycry
7EXT—erinnentlal
h ft. fr.
ar`e OGroundwate-,Remediarion fL fr'
ge and Recov ::541�`B383:Y [i'4< b,::_..:: itleY:: ::::: ?:: ;::'•_:=•<>??::`::>:: :_:>:_s>: :; ::;:::t:s::>�7 OSalittikyBatria MATERIAI. FMPLACHMENrMETHOO
FROM ro
❑Storrnwater Drainage ir. fL
Technology OSubsidence Control fL iL
❑Geothermal(Closed Loop) ❑Tracer
: ?PL$F�i {lL:i'aFf3cq'dYic9i�Eyit(Saf,..,,•,:,:.`-.IE::EiFt%4::'fati:<::iE:Ei>':;::>;; :,,.':Ei
❑Geothermal(Hearins/Coolino Retum) OOthe (explain under;*21 Remarks) FRogf TO D>seRlPTrov touluLtradnes rode ?ram, ffLI
ft. fL 0t
4.Date Well(s)Completed-' ,/✓d ZOW�� ft, /� ft.. /`
5a-Well Location: fL 9 ft. ,ft.
Facility-/OarerNarne FacilitV M#(if applicable,, fr. fL
'7a ,ra,�J ) _ '♦ ft. I ft- �+.
Physical Address,City and Zip F
ft. fL
�7r G 'Z$;RRT4�'.}i;':'ai: `t2=6?;=;:?3:3•`:4:i:i:i;,.k;i``;:::::::..:.
t-°urav
aazel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutesiseconds or decimal.degrees tirrtw,e, 1 tilt Y• ��. t
(if well ticld,one Iavlong is suficicnt) L
22.Certifi 'on:
} R
6.Is(are)the well(s): I'JPermauent or ❑Temporary Si=zr ofCen-d w 1 Contractor pate `
Ersigning t4s1orm.lirrreh!rrrift riser the+vr1l(sl+ s(srmJ<rotrsrrucred in acmrdmx•e::irh
7.Is this a repair to an eiistiag weiL- ❑Yes or ��o /5.-!NG1C 02C.OlOn ar lS.a hC,IC 02C A20n Ttf]/Cortmvction Standards and that a cram•
If rhis it a repair.fill our knor.a well ranslnrction info,matinn and explain the noarrr of the afthis rrcord has been prarided m the v-r/1 oxwcr.
repair under:'2/remm-ky season or on the back oftltis form.
23.Site diagram or additional well details:
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.only I GW-1 is needed. Indicate TOTAL RVMBER of wells (add'See Ovee in Remerk,Box).You may also attach additional es ifnec
drilled: '. P� ��ty.
24.SUBMITTAL INSTRUCTio-is
9.Total well depth below land surface: �0 ( )
For multiple ur//s list all depilny if&fferenr(erample-3(200'and 2@1001 Submit this GW-1 within 30 days of well completioa per the following:
10.Static water level below top of casing 40 (ft 24a. For?ill Wells: Original form to Division of Water Resources (DWR).
ff nttter le.al is above casing.vse'+" ) Information Processing Uni4 1617 MSC.Ralei�NC 27699-1617
11.Borehole diameter-6 118 (W 24b.For Injection Wells:Copy to DWR-Underground Infection Control(IUC)
12.Well construction medlod.
Air Rotary Prom,1636 MSC,Raleigh_NC 27699-I636
(i.e.auger,rocvy_cable.direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
county environment2l health department of the cotmry where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Is producing over'100 000 GPD-Copy to DWR,CCPCUA
13a.Yield(gpm) Method oft._Air Lift Permit Pro_ram,1611 MSC.Raleigh-NC 27699-I611
13b.Disinfection type: Chloe. Tabs ,amount i 1/2 Lbs
Form GW-f North Carolina Duparrmcnt of En.ironmcntal Qualiry-Division of Ware Kccaaccc
Revised li-E-_,
OI x