GW1-2022-09879_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1} For Internal Use Only:
1.Well Contractor Information:
Alfr
ed Kieslin Sr
M TO DESCRTMON
Well Contractor Name to ft. Ct- © J
2670-A eft p .-ft. ,�q ©�C/
NC Well Contractor Certification Number /
- `' ti'r'mi�cascstC....... 'ial¢Eiic <::: ::...•.).::•;;:::�: <;>i:i":;:
1��F1TE3 ''i51
B & K Well Drilling Inc FROM TO MCNIETER THICKNESS KATERLAL
Company Name
0 ft. I, ft. 61/4 1° SDR-21 PVC
<:>-
`.:i;2&'3LV3VERiC;' <F#1.#ELISLKG: �etlie�alel¢sed�"� :
2.Well Construction Permit :_y.._ta ��el-5 ON[ To DIAMErelt THICKNESS MATERIAL
LLst all applicable well construction pennitt 1.e.UIC.Corarrv.State.i'ariance.etc.) ft. ft, in.
3.Well Use(check well use): ft. ft. in-
Water Supply Well: _._ _ ...
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft
❑Geothermal(Heatiu4C.00ling Supply) 2<idetttial Water Supply(single) ft. fL
❑lndusuiaKommercial ❑Residential Water Supply( (shared)
❑Irrigation ❑Wells>100,000 GPD FROM To X-ILTERinL E*Lrl"FE�>`T METHOD&..01OUNT
Nun-Water Supply Well: D rt 20 ft- Bentonite Pour
❑NMonitoring ❑Rrx:occry ft. ft.
Injection Well:
ft. Ir.
❑Aquifer Recharge ❑(irouudwater Remediation :.:.:.;.:..>-:;;,: .,.:>:;:,::::::- >;:•:•::::•
a14 .:......... ...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I F,MPI-4CEMEW METHOD
❑AquiferTect ❑StormwaterDrainage it. ft-
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer . .`z......
❑Geotbermal(Heatkg/Cooling Retum) ❑Other(explain under#21 Remarks) FRont TO DESCRIPTION(color.hardnttst sqwmk rype.gait NLe.ere)
ft. ft. /f
4.Date Well(s)Completed^ ',;J 2-21VellID# it. ft. if
5aa.Well Location: I / y ft• fL 11G /�
12 L-s
Facility/OrmerNamz ! Facility TT) (if applicable,, ft- fe
ft. fc '
._ll L, 1-44-21 Rj
-seal Address,City,and Zip ft. ft" O C T 2 g 2oLr-
r
i'Z 'ER1i;1S3ARIi; :
w 0 �l
County Parcel Identification No.(PIN) Ifltvrl?c'1+•+
5b.Latitude and longitude in de.-rees/minutesiseconds or decimal degrees:
(if we]I field,one latrlona is sufficient) 22.Certifi atiVn: -
N W
6.Is(are)the well(s): [nPermanent or ❑Temporary Simature Cenined Well onaactor Date
Brsi,ninS this form.}herebr renffr that the ivell(s)cans(were)constructed in accordance inch
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.010n or I5A NC1C 01C.0200 Well Coustr-uction Standards and that a cam•
#'rhis fs a repair.fill out knowp well consinaainn infonnatinn and erploh-,the naturr raj rho nfthis record hat heen prorided to the„rIl or Wirer.
repair rorder t21 remarks section or on the back of thus fortn.
23.Site diagram or additional well details:
8.For Geoprobe/DPI 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)NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S —(ft.)
For mulriple,ills list all depiln•if rhfferent(zromple-3@.L100•rnat?@100 Submit this GW-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 (DN'R),
(ft
If rtater level fs ubore casing.rue-+'. Information Processing Unit,1617 MSC.Raleigh-NC 27699-1617
11.Borehole diameter:6 118 ( ) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IiJC)
t Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method-.Air Rotary
24c•For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county em-2ronmenral health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) lt�
n Method of test:Air Air Lift Pit Program,1611 MSC,Raleigh.NC 27699-1 6 1 l
13b.Disinfection type: Chlor, Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-E-201 R