GW1-2021-00272_Well Construction - GW1_20210126

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris C. Russell 14 WATER TONES
Well Conlraetor Name FROM 10 OtBCR11-1 tON
3254 A 60 rt, 365 n
n. n.
NCAell Contractor Certification Number 15.OUTER CASING for tnahFeaed wNb OR LINER if lifq
Russell Well Drilling, Inc. FROM TO DIM IL THICKNEsti MATERIAL
0 1' 120 n 6.25 in.
SDR21 PVC
Company Name 16.INNER CASING OR TUBING eothermal elaxd-too
2.Well Construction Permit#: 307941 FROM TO DIA5IETER THICKN'F55 MATH L
Lutull uppliruble we(l comtrurtiunprrmits li.r. UIC,0,zorr orate. Variance,rt, ft. O. in.
3.Well Use(check well use): "- ft. in.
Water Supply Well: 17.SCREEN
most I TO DIMfETER SLOT SIZE TRICKNE55 MATERIAL
Agnculmml DMmicipal Public fc ft.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) (L ft. im
IndustriaVCommercial Residential Water Supply(shared) UL GROUf
Ilmigation FROM 1 f0 MATEIU.U. EMPLACEMENT METHOD&AMOENT
Noo-Water Supply Well: 0 ft. 20 n. Grout Poured
Monitoring 13Recovery n. It.
Injection Well:
Aquifer Recharge ❑Gmmdw atcr Rcmcdiation 19.SAND/GRAVELPACK , smilkable
Aquifer Storage and Recovery OSalmmity Banner FROM 1 TO MATERInL EMPLACEMENT\IET1101)
Aquifer Test [3Stortnwater Drainage A. n.
Experimental Technology Subsidence Control ft. I n.
Geothermal(Closed Loop) QTmcer 20.DRUJING LOG attack additional sheets lfoecessa
Geothermal(HeatingiCcialing Return Other(explain under 421 Remarks) momI to I DESCRIPTION cant,hemao, wlermk Inv,mrsis it.,arc.
0 f1. 115 n- Dirt
4.Date Well(s)Completed: 12-30-202C Wel IDk 115 n, 365 R- Rock
5a.Well Location: ft. ft.
John McCormick Piedmont Quality ft. R•
Facifily/Owner Name Yacihiy IDe(ifappliceble) ft. ft.
443 Hicks Rd, Statesville, NC 28625
Physical Address.City,and Zip
I redell 21.REMARKS
County Parcel Idria.&.iou No.(PIN)
5h.Latitude and longitude in degrees/min ites/seconds or decimal degrees:
(ifwell field one lat/long is sumcieut) 22.0 IRcalion:
35' 40.360 N 080.55.100 W
1-8-2021
6.Is(are)the wel(s)OPerimment or OTemporary Sigmturc ofCcrotielf 0411Conmactor Date
By signing This form.I herebv re odii mat the wells)maa(were,c r'Wrucled in aemrdanoe
7.Is this a repair to an existing well: Yes or E)No ahh 154 NCAC 02C,0100 or I5A,NCAC 02C-0200 Well Cormtracdoa Sr do'ch and thin a
If thi.i.a,,pair,fill out knoim.ell oon.nvorian inf rmntiun and explain the mrurr f of, vaPt-ofthi,record ha,been prandial m Inc s.r0 umnrr.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well dents:
S,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
n '1
9.Total well depth below'land surface: 365 1._ � LWO4 a. For All Wells: Submit this lone within 30 days of completion of well
For rouln'ple welts liar all depthv i(dilj rent(example-3(ai200 and 1(ajl0d') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing llmit,
If imter react"above casing use` 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this form within 30 days of completion of well
12,Well construction method: construction to the following:
(ice.auger,many.
ry,cable,direct anti etc.i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Air 24c. For Water Suvak& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 da)'s of
13b.Disinfection type: HTH Amount- 1 cup completion of well construction to the comfy health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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