GW1-2023-00521_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD(GW-1) For.Internal Use Only:
f ;
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DFSCRIPTION
Well Contractor Name
3254 A 20 ft 325 ft
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 it. 31 ft 6.25 : in. SDR21 JPvc
Company Name
E H W22-06059 .16.INNER CASING OR TUBING' eothermal closed-loo
2.Well Construction Permit#: FROM I To I DIAMETER THICKNESS I 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.17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
[]Geothermal(Heating/Cooling Supply) ZResidential Water Supply(single) ft• g• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM 1 TO MATERIAL EMPLACEMENT 51ETHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO' DESCRH'TION color,hardness,soil/rock min size etc.
0 ft- 26 ft- Dirt
4.Date Well(s)Completed: 11-29-2022 Well ID# 26 It- 325 ft- Rock
Sa.Well Location: ft. ft N '� i....� :_:;
Raymond Joseph Jonathan Scronce ft. F ft. A a
Facility/Owner Name Facility ID#(ifapplicable) ft. fL _ V
7161 Parker Farm Rd, Cherryville, NC 28021 ft ft
g..r
Physical Address,City,and Zip ft., ft _.. _.
Lmcolnton .21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
35' 43.986' N 81' 45.395' W - 12/6/2022
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified well ontmctor 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 at 1!lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well conshuction information and explain the nature ofthe ofthis 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 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 ifdierent(example-3@200'and 2@100D
10.Static water level below top of casing: 20 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
6.25 24b.For Infection Wells:Copyito DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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) 12 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 cup
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l Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018