GW1-2022-09877_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW D For hitemal Use Only:
1.Wed Contractor Information:
Alfred Kiesling Sr
..::..............
Well Cout.actor Name FROM TO DE.�CRIPrrO\
2670-A ft- -
O fc. yy
NC lt%oll Contractor Certificationft.tion Number C vt✓
B & K Well Drilling Inc FROM
FRO TO DIAMETER TfI1C1�IvE55 MATERIAL
Company Name Q ft. I ft- 61/4 in- SDR-21 PVC
3 5 4 - 1 >� a <> ii; ;mom'-•..,:.:
2.Well Construction Permit m:_ a'6 ExoNI To DIANIFI—ER THICKNESS MATERIAL
Liar all appl•'cablc•well constnleLonprrmits .e.U1C.Cororrv.Susie.Ya ante.erc) f6 i fr- in.
3.WeU Use(check well use): ft_ fr. in-
Water
PPY Well: SCR !F: :<�:z::z::]::'::e;�r:>;'::<:::: r:>; :»:..>::>::::ia;<>:z�.::: ;:3z::::;;: :<i �>;:•::; ...:
FROMTO 1 D1AMEfER $LOTSIZE THICKNESS MATERIAL
OAgn'cultutal ❑Municipal/Public R. ft_ is
❑Geothermal(Fieatinv%Cooling Supply) �dcntial Water Supply(single)
Tt. fL In.
❑industrialtCommercial ❑Residential WaWr Supply(Shared)
❑Irrigation O Wells>100.000 GPD [font roNiERiAI E*st ncr.ArEraon&.tirotrvr
Non-Water Supply Well: Q ft_ ZQ ft_ Bentonite POUF
Oklonitoring ORccovcry fr. fr.
Injection R'e1L
❑A uifer Recharge Groundwater Re-mediation
OAq Storage uiferSt and Recovery OSalrtttty Bar
rier =sFROM
. . ...�. .::.:..::.
FR(7M TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormw•ater Drainam ft. ft_
OExpelimetnai Technology OSubsidence Control ft. it•
❑Geothermal(Closed Loop) ❑Tracer
::z7.t#`•PkL�L�I!7��-0C's�cti's�liciiaEee�e&�ack2:�:>::>:':::::<:`';r?3f>:�,.:';;:::'.:"•>
❑Geotbermal(HeatinJCooling Mum) ❑Other(explain under#21 Remarks) BRont ft. ft.To DESCR O�(Dolor.hardncis rook ,rain size,etc.)
` -P 6'©1
4.Date Wells)Completed- d ' We11II3# ft. (! ft. 0�
52.Well Location:_ ft. t ft. 1 r
ft. ft.
Facility/( IrNamt Facility M)6172pplicable) ft. fe
e v� 1 Y fr.
h ical Address,City.and Zip ft, fL
- r �
�• `�O l f�O ! �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-oll field,one ladlon.-is sutFcient)
2"Certifi
N
R /
I
6.Is(are)the well(s): r Perruauent or OTemporary OSI -fck—i'i'�,-
w Corttracor Date
L?rsigain�rhislonm.l hereto•rertifi tiro[rnr+:rll(s/+cnS(rrrrr)<•onstracred in acc-orda+xr:rirh
7.Is this a repair to an existing well: ❑Yes or 1 SA NCAC 02C.0700 or d-1 A'CAC 01C.0100 UW Cons[uciion Standards and that a coirr
11 this Ls a repair.fill out knee well<nnsrrrn:ricer infonnatinn and etnlair,rho norvrr ofrhe of[iris retard has beemprm-lded to rho xrll ouncr.
repair under t11 remarks sacdon or on the back oJthis form.
23.Site diagram or additional well details-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consruction info
construction.only 1 GW-I is needed. Indicate TOTAL NFUMBER of wells (add'See Chet'iu Remarks PG.-).You may also anach additional pages if necessary.
drilled: j
�I] r 24.SUBM['["CAL l-NSTR[;CTiONS
9.Total Kell depth below land surface: OW ( )
For multiple Hills list rdl dcpflts tftkfferent(trample-3(ar_00'and 3(d)1001 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),
/f water/ere/is abote casin,.use '+•- Information Processing Unit 1617 MSC.Raleigh NC 27699-1617
11.Borehole diameter:6 1/8 24b.For Injection Wells:Cony to DWI-Underground Injection Control(Ii1C)
/�
o Program 1636 MSC,Raleigh,1vC 27699-1636
12.Well construction method:A Rotary Dtary
(i.e.auger,rotary.cable.direct pu k etc.) 24c.For Water Supply and Opeo-Loop Geothermal Return Wells:Copy to the;
cotmty ennronmenm1 health departn)ent of the cotmty wdterr im-talled
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100.000 GPD•Copy to DN'R,CCPCUA
13a.Yield m .Air Lift Permit Vrogra 1.1611 MSC.Raleigh.NC 27699-1 61 1
(� ) Method of tesE.
13b.Disinfection type: Chlor. TabS Amount 1 1/2 Lbs
Form GW-f North Carolina Department of Ene iroamcnral Quality-Division of Ware Atso+accs Revised 6-6�1019