GW1-2022-00141_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only.
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I.Well Contractor Information:
Alfred Kiesling Sr °
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Well Contractor Name FROM i TO I DESCRTPITO\
ft. ft.
2670-A
NC Well Contractor Certification Number fL
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B & K Well Drilling Inc FROM I r0 D1AnElER THICKNESS I MATERLAL
Company Name
0 fr 1.1 fr 61/4 1° SDR-21 PVC
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2.Well Construction Permit R:_371 '` .,L txo�t I ro VIA-METER I THICKNESS IntATERI:tL
Liss all applicable well cousrrucCrort penn(ts,;.t•.LIIC Comrni.State.Variarrte.crc.j ft.
3.Well Use(check well use):
t?'I:7_SQ� 1)F>`:<si:-::2:;;:+::i%<i':i;:::;:i:<:;i4;<`'r':c:<Y•f'•::';:°x:?:r:7aiifi >:::a:;,. ...
Water Supply Well: . .:...:..::.:....::..:,...... :::....:::.,::,....:.:.. ..,::.,...,....:.,.:..,........:
FitOM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL is
❑Geothermal(Heating/Cooling Supply) 24idential Water Supply(single)
ft. f[_ iD.'
01ndustrial/Cornmercial ❑Residential Water Supply(shared)
1?i$i+Gftt3t3'#'zi
❑Irrigation ❑We]Is>100,000GPD FROM TU..... MATERIAL L%JPLACEdEhTMETHOD&.AD(OU.W
Non-Water Supply Well: 0 rL 20 fL Bentonite Pour
OMonitoring ❑Rccoccry ft. ft.
Injection Well:
❑Aquifer Recharge OGrouudwater Remediation ft ft❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, I EMPL4.CEn1ENT METHOD
❑Aquifer Test ❑Stormwmter Drainage fL ft.
❑Experimental Technology ❑Subsidence Control fL ft. 1 `
OGeothermal(Closed Loop) OTracer
;iNG�OG`attadi�a&tl�ieria>;+3etts�si; a�lz?::>%�::><>z:`:=^:::?:=t•`.vS;::::•s<:r•,:;'
DGeothermal(HeatinJCooling Retum) ❑Other(explain under#21 Remarks) FROM To DEs ov[coror.bardrress so r ock n �size etel
fL ft. r
4.Date Well(s)Completed 2?zlvell ID# `fr. ft. //i>7!/,�
5a.Well Location:- Ct. ft. ,pf 1
(/ ft. t D ft. /elzi
FacilitylownerName Facility M#(ifapplicable,, ft. fL
16S' QJ-,. o l l�w dui,. - Aa 4 17 . ft. i fL
Ph -ical Address._City.and Zip fr. ft
2 :
............:,...:,:..
County P r.•�'_ '+^7 P'i;7=�^,•..`. unh
Parcel Into+:ac��:::� ., -7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one IaUlong is xufficicnt) 32_Certification: %
N w �✓� IY � V
6.ls(are)thewell(s): (nPermanent or DTemporary 5_=zs of`CCni5ed Weff Contractor Date
Brsi;nin�lF.is••Jbrnt,lhereFt•rer7ifr mar rirr :wlJ{sl+cgs{lucre)<ronstrurrrd in arrnrdmtre+.irh
7.Is this a repair to an existing well: ❑Yes or !JNo 1.4:VC:4C 02C.0I0n or lie hC.IC 72C.0200 ITeR Cmutrucriot Standards and that a corn
!/•rhis is a repair.fill our kaonrz well t-ansinwfion informminn and amlalr,the narurr of rhr, of this reenrd has&-errprorided to the v.r11 owner-
repair corder-#2/remarks section or on The back of rhlsform.
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 construction info
construction_only 1 GW-1 is needed. Indicate TOTAL NFUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necemary.
dried. t _ 24.SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: (fQ
Fur•muhiple weds list all depilu ifdtfferenr(erample-3(a1100'aat12@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below tap ofeasing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)lj uvler leer/is abuse casing.rr'r"+ �+Information ProcessingU 1617 MSC.Raleigh NC 27699-1617
" �
11.Borehole diameter:6 1/8 (in) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:At r Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.super,rotary-cable,direct push,etc.)
cotmry entuonmenral health departmen
I t of the county whets installed
FOR WATER SUPPLY WELLS ONLY: : '
14d.For Water Wells producing over 160.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test•
Air Lift Permd Program,1611 MSC.Raleigh.NC 27699-161 t
16 1.,
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 LUS
J.
Form GW-I North Carolina Department of En.aoamontal Quality-Division of Water Roso rccs Revised 6.6-30[A
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