GW1-2021-03288_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES,
FROM 'to DESCRIPTION
Well Contractor Name 60 ft- 185 ft
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 98 ft- 6.25 in SDR21 I
PVC
Company Name
2883749594 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1FROM7SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in,
1ndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 D- Grout Poured
Monitoring Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remcdiation
19.8AND/CRAYEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control ft. fr.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock rain size,etc.
Geothermal(Heating/CoolingReturn) ;Other(explain under#21 Remarks 0 tt. 93 [t. Dirt
4.Date Well(s)Completed:4-27-21 Well ID# 93 ft 185 ft. Rock
5a.Well Location: ft. ft.
Crystal Toiler Competitive HouseKr
ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
4807 Lackey PI. Lenoir, NC 28645 ft. ft. 02
Physical Address,City,and Zip ft. ft. Djt
Caldwell 21.REMARKS r "
County Parcel Identification No.(PIN)
' � p�,NR Ssctl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cer• Cation:
36' 01.925' N 081'40.787' W
5-3-2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Cbntractor Date
By signing this form.I hereby certify that the wel/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or E)No with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consnuction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welly list all depths ifdii ferent(example-3(a3200'and 2L100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If evarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
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,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 test: Air 24c.For Water Supply&Injection 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: 1/3 Cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

May 28,2021
Information Management
Division of Water Quality
1617 Mail Service Center.
Raleigh,NC 27699-1617
Subject: Well Construction/AbandonmentRecords
Dear Information Management:
Enclosed are well construction/abandonment"records for the following locations:
Location Job# Date,,
548_West',32nd Street; Charlotte,NC 13589 05/24/21
1901 Brookdale Avenue; Charlotte,NC 13592 05/24/21:
1228 Carroll Street; Durham,-NC 13562 05%14/21
1125_Cherryville Road; Shelby,NC' 13593 05%24/21
Sincerely,
Karen Byer
SAEDACCO, Inca
Enclosure'(s)
9088 Northfield Dr. ♦ Fort Mill,SC 29707 ♦ www.saedacco.com.♦ [phone] ♦ Phone [phone] ♦ Fax [phone]
South Atlantic Environmental Drilling and.Construction Co