GW1-2022-08791_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES :<
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 ft 325 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multl=cesed'wells OR LINER"if a Itcahle ,R tr
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft 93 't 6.25 i SDR21 JPVC
Company Name 6 y,
EH W22-00449 16;INNER CASING OR:.. ING eotherm'alA ed46o -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft f t i°'
3.Well Use(check well use): ft. ft. in.
17SCREEN :. !
Water Supply Well: FROM I 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) 18r.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 'i' 20 ft Grout
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft it.
❑Aquifer Recharge ❑Groundwater Remediation
191SAND/GRAVEL.PACK ifs"7icalite.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD t
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer :;20:=DRILIIlVGLOG attachUdditionalsheetsif-necessa' d;
FROM TO DESCRIPTION color,hardness,solUrock e, in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it- 88 ft Dirt
4.Date Well(s)Completed: 8-5-22 Well ID# 88 't 325 ft Rock
5a.Well Location: ft ft .4 _- !44"
Randy Stein ft Facility/Owner Name Facility ID#(if applicable) ft %
Lot 2 Carter Trail, Lincolnton, NC 28092 ft. ft. ltrf;; ;�a:_� ;ac a2 Un,
Physical Address,City,and Zip ft. ft W i
Lincoln 2li.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatllong is sufficient) 22. rtification:
35' 47.591' N 081' 19.605' W - 8/12/2022
6.Is(are)the well(s): ®Permanent or ❑Temporary Signaturt of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 0.2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 I GW-I 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: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(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: 60 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use-+"
il.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copyjto DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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) 20 Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
1�
4�
13b.Disinfection type: HTH Amount: 2/3 Cup
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018