HomeMy WebLinkAboutWELL-12-2015-067314.TIF f• �1r081609:03p Russell Welling Drilling 8286322617 p.1
•
•s•
>e
s
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Infornvtion;
Chris Russell 14.WATER ZONES
Well Coca-actor Name FROM 10 o CmITroN
3245A !CD ,t kr R.
ft. fa
NC Weli Contractor CcruEco:ion Number Inc. IS.OUTER CASING(for multi-casedocile)OR LINER(if oplicahle)
Russell Well Drilling, c 'ROM 10 DIAMETER THICKNESS I MATERIAL
Company Name _0 ft. Li(0 ft. le a s `a. s jug z 1 Nc
2. WELL-12-2015-067314 16.LNNER CA5TG OR TUBING(geothermal closed-loop)
Well Construction Permit it: FROM TO DIAMETER THICKNESS MATeauL
DO tilt applicable null canavacrion pc-nails 6.r.LAC,County,Suite, Vartance,etc.) ft. ft. ins
3.Well Use(check well use): ft. ft. in.
Water Supply Well: Ti.SCREEN
FROM TO I DIAMETER SLOT SIZE I THICKNESS MATF.RIAL
DAgncutwral OMunicipalPu'blic ft. ft. I in.
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) IL rl- I in.
Olndustrial/Commtxcial ❑Residential Water Supply(shared) Th.GROUT
Obligation FROM TO IMATERIAL 1EMPLACEMENTMRTHOD&AMOUNT
Non-Water Supply Walt 0 IL ,R0 R. GfLrlal l rcr1(eci
Monitoring )Recovery D. II.
injection Well:
ft. R.
Aquifer Recharge OGroundwatcr Rc :cdiation
19.SAND/GRAVEL PACK(if applicable)
T.Aquifer Storage and Recovery _1Sai;nity Battier FROM TO MATERIAL I EMPLACEMENT METHOD
)Aquifer Test DStolrnwater Drainage ft. n. I
DExperimental Technology ❑Subsidence Control ft. R. 1 I.
❑Gcotherrnal(Closed Loop) ETmcer l 20.DRILLING LOG lattach additional sheets if necessary)
❑Geothermal(Readng/Cooling Return) DOther(explain under 221 Remarks) FROM To DESCRIPTION(cola,McNaev,coil/leek type,pain ma.eta)
3-8-2016 0 ft. ; V3 ft. 7)' 112*
4.Date Well(s)Completed: Well lDI/ l3 rL ic,QD r°
-Rock-
ft. ft.
Se.Well Location:
Elena Pritchard-Daniel Belose rt. ft.
FacilityfOwrcr Name Facility IDP(if-applicable) f• ft. I
Deerfield; 6373 Willowbotdom Rd, Hickory NC 28602 f• ft.
R ft.
Physical Address,City,and Zip
Catawba 21.REMARKS
County Parcel Idcmilicaton No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. toe lal orig is euffnrnt) j' rtifi lion: ' 9
35' 38.604' 081' 23.735' 'V • 3-8-2016.
6.I5(are)the well(s): MPermanent or ❑Temporary Signatuat o;Ccr eel Well Contractor Date
Rv.signing this farm. I hirer,'cerfifv this:the sear";wag;were;coaetraced in a¢tirdoncf
7.Is this a repair to an existing well: Dies or •No with ISA NCACO2C.9IO(1 or)5A NCAC 020.020CI Well Construction Standards and Arate
If then it a repair Jill cur F.avr:well construction information and eaplein the nature of the copy of Ong mcond hot nen provided to the wet/owner.
repair under 021 remarb section or an the back of this fn. 23.Site diagram or additional well details:
I.For GeoprotoDPT or Closed-Loop Geothermal Wells having the snore You may use Bic back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofweds construction deails. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth blow land surface: 600 (ft) 24a. For All Wells: Submit this forrn within 30 days of completion of well
For malt:ple wells lies all depths Ifdpren!(ample-3,&?Oil and 2(81901 eOastnaClioo to the following:
ill.Static water level below top of casing: 1 00 (ft.) Division of Water Resources,Information Procesaing Unit,
If water level is above casing.use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (i1) 24b.For Injection 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 SUrP]PLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test:Air 24c.For Water Snook&Injection Welds: In addition to sending the loan to
T J 1 O the adUres5(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: H I I f 4mount: I 2/3 cup completion of well construction to the weeny health department of the county
I where constructed,
Form G W-! Nonb Carolina Department of Enviroamertal Quality"Division of Water R.tmuccs Revised 2-22-2016