GW1-2021-00493_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
FROM TO DESCRIPTION
Well Contractor Name 3254 A 40 ft. 200 ft.
ft. R.
NC Well Contractor Ccrtificetion Number 15.OUTER CASING for multl-cesed wells OR LINER f a ticable "
Russell Well Drilling, Inc. FROM TO DIAMETER THICKT�SS MATERIAL
Company Name
0 ft. 67 fL 6.25 'n SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: EH2O-07527 FROM I TO DIAaETER I TMCKhESS MATERIAL
List all applicable nail construction permits(t.e.U/C,County State,Variance,etc.) ft• ft•
3.Well Use(check well use): n' f' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL fL in.
Geothermal(Heating/Cooling Supply) ORmidential Water Supply(single) ft, ft. in
IndustrialtCommercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 A- 20 ft- Grout Poured
.Monitoring Recovery fL ft.
Injection Well:
Aquifer Recharge [3Groundwatcr Remcdiation
19.SAND/GRAVEL PACK: fapplicable)
Aquifer Storage and Recovery 0saunity Battier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage R ft•
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRII.LINC LOG attach additional sheets"if necessary)
FROM TO DESCRIPTION color,hard sotltrwk rain stir etc
Geothermal satin Coo• Return) Other(explain under#21 Remarks O ft' 62 fb Dirt
4.Date Well(s)Completed: 1-13-2 1 Well ID# 62 R' 200 R Rock
5a.Well Location: ft. ft.
Radke Properties Radke Properties ft. ft.
Facility/Owner Name Facility ID#(if applicable) H' H•
977 Ivey Church Rd, Maiden, NC 28650
Physical Address,City,and Zip ft. ft.
Lincoln 2LREMARIG
County Parcel ldentificatioallo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laUlong is sufficient) 22.Certification:
35' 33.012' N 081' 10.696' W
6.Is(are)the well(s)oPermanent or Temporary Ss'igoaaue of Certified Well Contractor i Date
By signing this form.I hereby certtfy that the uwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
#[this is a repair,fill nut known well comtruction information and explain the nature of the copy of this record has been provided lei the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well detalls:
8.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i� a a --..SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 200
(f)'24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoWent(example-3@200'and�fa110 �1 q construction to the following: j
10.Static water level below top of casing:40 , CC i L 02> .) Division of Water Resources,Information Processing Unit,
If water level is above casing.use'+" ° v ...; 71 7 7, 7 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 in) .',_ 'l"
( 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of t
Air Drilled his form within 30 days of completion of well
12 Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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 of teat:Alf 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1�2 Cup completion of well construction to the county health department of the county
where constructed. G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016