GW1-2021-01596_Well Construction - GW1_20210419

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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 DESCRIP•rION
Well Contractor Name 60 ft- 365 ft.
3254A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedcwells OR LINER if a livable
Russell Well Drilling, Inc. FROM T( DIA LIFTER THICKNESS MATERIAL
Company Name 0 ft. 94 ft- 6.25 SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: RSA W ZD�0& ( � FROM TO DIAIIIETER 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. it. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERTAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in-
Industrial/Commerciai DResidential Water Supply(shared) 18.GROUT
_ lrri ation FROM TO - MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Grout Poured
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/CRAVEL`PACK(if applicable)
Aquifer Storage and Recovery DSahity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) nOther(explain under#21 Remarks FROM To DESCRTPTTON color,hardness soil/rock type,grain sic ctc.
0 ft• 89 ft- Dirt
4.Date Well(s)Completed: 3-9-2021 Well ID# 89 ft. 365 f• Rock
5a.Well Location: ft. ft.
Frankie Alan John, Jr. John McCormick ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2363 Carriage Lane, Lincolnton, NC 28092 ft. ft. :1� s
Physical Address,City,and Zip
Lincoln 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'''vs
(if well field,one lat/long is sufficient) 22. ertifieation:
35' 31.836' N 081' 16.12' W
3�/8�2oat
6.Is(are)the well(s)E)Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.1 herebv certify that the well(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EJ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature nfthe copy ofthi.s record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
A.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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiflvrent(example-3L200'and 2(a3100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
Ifwater 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) 10 Method of test: Air 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 Cu p 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