GW1-2023-02334_Well Construction - GW1_20230331

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
So f t. 265 r
3254 A .
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multl-cased wells OR LINER if a licable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS nATERIAL
0 ft• 76 ft- 6.25 In SDR21 JPVC
Company Name
E H W 21-06063 16.INNER CASING OR TUBING(geothermal closed-loop)_
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,l7ariance,etc.) ft. ft. in,
3.Well Use(check well use): tt. ft. in.
17.SC
Water Supply Well: FR BE M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply), ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillreck e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 1" 71 ft- Dirt
2-20-2023 ft. ft.
4.Date Well(s)Completed: Well ID# 71 265 Rock i. -' :.v,
5a.Well Location: ft. ft.ft
D 'a' y n2
Dustin & Taya Hester ft. ft. Y^ ,Ie
Facility/Owner Name Facility ID#(if applicable) ft. ft
1499 Boy Scout Rd, Lincolnton NC 28092. ft. er
Physical Address,City,and Zip it. ft.
Lincoln 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
35' 436.24' N 081' 280.02' W /y 3/14/2023
6.Is(are)the well(s): 531'ermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the welt(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of die 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 construction info
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwa[er level is above casing use"+"
6.25 24b.For Igleetion Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)40 Method of test:Air
Pemlit Program,1611 MSC,Raleigh,NC 27699-1611
r1
13b.Disinfection type: H 1T H Amount: 2/3 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018