HomeMy WebLinkAboutWELL-01-2016-068429.TIF ••fir 14 16 08:10p Russell Welling Drilling 8286322617 p.1
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name -40 It. �rlf R.
3245A fL lJ It.
NC Wd!Coraaaar C-rtificatlnn Number Inc. IS.OUTER CASING(for multi-cnad wells)OR LLNER(ifap linable)
Russell Well Drilling, c FROM 10 DIAREIER THICKNESS MATERIAL
1L L
C tap 1,-.)5-1,-.)5- tm SD .ii Pic
Company Name }6 INNER CASING OR TURING(geothermal dosed-loop)
WELL-01-2016-068429 FROM 10 DIAMETER TRICK.\ESS I MATERIAL
2.Well Construction Permit It;
ft ft in.
Liu all aprdimble nett construction permits E.e. LUC,Coady Date,variance.etc)
n.
it I rn I I{
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
°Agricultural OMunicipal/Public ft. EL in.
OGeothemlal(Heating/Cooling Supply) °Residential Water Supply(single) ft n, in.
❑lndustiauCornmcrcial °Residential Water Supply(shared) : to CROW'
❑Irrigation ' FROM TO MATERIAL ENLACEMENT METHOD&AMOUNT
Non-Water Supply Well: In ft 020 ft Go:3,4 l W IQ d
❑Mtmilofing °Recovery V R. ft. l^
Injection Well: R. ft.
❑Aquifer Recharge OCmoundwaicr Remodiatiou 19.SAND/GRAVEL PACK(if applicsbk)
❑.Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACCMLVr nsvr000
❑Stoonwater Drainage ft. ft
❑Aquifer Test
°Experimental Technology °Subsidence Control ft. fe I I
°Geothermal(Closed Loop) CTncer 20.DRILLING LOG(attach additional'beets If necessary)
FROM TO DESCRWrInN(colon hardness.sawreck type,gram cht,nrl
DGeothennat(licating/Cooling Return))C Daher(explain under 021 Remarks)
O It. //S ft I Dbit/
4.Date W'ell(s)Completed: 3-3-1 Well!DU I(5 ft" ,gill R I RDC
fL ft. •
5a.Well Location: •
Phillip Welch (Clayton Homes) H. I<
Facili ID/I ife licable ft ft
FncilirylOwrva Name tY ( PF )
2147 Hewitt Rd, Claremont NC 28610 ft. D.
ft. n. I
Physical Address,City,and Zip
Catawba 21.REMARKS
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(lfwdl field,one Wrleng is sufficient) 22.C Icati :
35' 41 .716' rc 081' 06.643' W / 3-14-2016
Nigerurc of Cenrned Wel Contractor Das
6,Is(are)the well(s): (Permanent or ❑Temporary r
By sgminf this firm. 1 hereby car ift that the welds) wad(were)corer ru ore in accordance
7.Is Ibis a repair 1n an existing well: °Yes or ENb wah 15A NCAC 02C.0100 or ISA NCAC OaC.200 Well Gon.vnucnan Standards and that a
If this G a repair.Jill cut known well ronntn can,,information and explain the nature of the "'BY gethtr taco J has bon provided to the well owner
repair undo Si?]remark•section'or an the had nj This firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional will site details or well
8.For Geoprabe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate'iUTAI-h'lilv(RER of weds
construction details. You ntay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulsipk wells fit ail dept/,If different(mple-3@ 90'and2C/606 construction to the following:
10.Static water level below top of easing: 40 (ft) Division of Water Resources,Information Processing Unit,
lftwter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) Mb.For Injection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this fore within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,romry,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) 20 Method of len:Air 24c.For Water Supply$c Injection Wells: In addition to sending the form 10
2/3 Cup the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection tape: HTH {mount:
completion of well construction to the county health department or the county
where construct-
Fenn GW-I NortIL Curoliru Dcparmmnt of Environmenta l Quality-Divieion of Water Resources Revised 2-22-22016