GW1-2021-00490_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14•WATER ZONES
Weil ContractoT Name FROM M DYS47 r 10N
3254 A 40 "• 200 "
R. R.
NC Wcll Contractor Certification Number 15,OUTER CASING for oultl-caved wdb OR LINHR f liubk
Russell Well Drilling, Inc. FR(1M TO DIAAIETER TNICKNLa MATERIAL
Company Name 0 " 67 " 6.25 1n SDR21 I PVC
EH2O-07527 16.INNER CASING OR TUBING eolhermal Barra
2.Well Construction Permit#: FROM I TO I DIAMETER TRI(XXIM MATERIAL.
List all applicable nell construction permits(i.e.UIC.County,Sttue, Variance,eta.) A. I ft. in.
3.Well Use(check well use): n. I D. id
Water Supply Well: 17.SCREEN
iROM TO DIAMETER SLOT SIZE IIRCKNES.S MATERIAL
Agricultural OMunicipal/Public R ft Ia.
feothermal(Heating/Cooiing Supply) ®Residential Water Supply(single) it. f4 is.
Industrial/Conume cial Residential Water Supply(shared) 1&GROUT
Ird •lion FROM i0 MATERLIL EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 0 "• 20 ft. Grout Poured
Monitoring pRecovery n. R.
Injection Well: n. R.
Aquifer Recharge ❑Groundwater Renci iatiun
19.SANO/GRAVHL PACK f
BernerIpbk
Aquifer Storage and Recovery Salinity Baer FROM TO MATERIAL EMPLACEMENT aIETNOD
Aquifer Test OStormwster Drainage N. R
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) E)Tracer 20.DRILLING LOG attic\a klidotal saints R necessary)
Geothermal eating/Coo Return) Other(explain under#21 Remarks mom TO DESCRTPTION rnwr errs wnhuca tam car de)
0 f1• 62 ti Dirt
4.Date Wel(s)Completed: 1-13-21 Well ID# 62 " 2001• Rock
Sa.Well Location:
Radke Properties Radke Properties
Facility/Owner Name Facility m#(ifapplicable) it. "•
977 Ivey Church Rd, Maiden, NC 28650 n. n.
Physical Addnaa,City,and Zip "' I "'
Lincoln 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field one IeUloog is sufficient) 22.Certification:
35' 33.012' N 081' 10.696' W / - D,l/ , U
6.Is(are)the well(s)OPermaoent or Temporary Si11m�ofCenifiedd Well Contractor Date
By signing this form.I hereby cerafy chat the%ell(s)noes(isers)missirumed in accordance
7.Is this a repair to an existing well: OYes or ®No with 15A NCAC 01C.0)00 or ISA NCACO1C.0200 Well Co�ssvuction Standards and dint a
ff 1hu&a repair,fill nut known well construction inliamotion arul explain the nature of the cnp_y of this record has been provided in the%ell Owner
repair under#21 remarks section or on the bad of this form.
23.Site diagram or additional well details:
R.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
consmlction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also amach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ff-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifiloereer(emmple-3@200'mu12(410/)1) q;1 construction t0 the following:
10.Static water level below ofcasin .� 2u'top g:40 44-) DlWeloo of Water Resources,Iaformaton Processing Unit,
Ifwater level is above casing.rde"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b,For Infection 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:
(i.e.auger,rotary,cable,direct push.tic.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method or teat: Air 24c.For Water Supply&laiectioa Wells: In addition to sending the form to
the adcims(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount 112 cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonh Carolina Department afEnvironmentd Quality-Division of W ater Resaarces Revised 2-22-2016