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HomeMy WebLinkAboutWELL-03-2022-167730.TIF g 6PW-oW-a) 3ein3 WELLCONSTRUCTION.RF.CORD(GW-1) For Internal Use Only: I..Well Contractor Information: Chris:C Russell U WATERZON6S AYr. :v1 c ti' :t 4 •r.- ,—;._ L'nntta4Y11r Game FROM TO DESCRIPTION WCII 3254 A so • ft• 200 a D. NC Well Cunimdor Certification Number15.•OUTERCASING(for muld-eased went)OR LINER 0/ap Restyle)v--3C:'•4:Sd Russell_Well Drilling, Inc. FROM 'ro DIAMETER THICKNESS MATERIAL. CompauyNatik 0 h• 63 nr 6.25 in. SDR21 PVC WELL-03-2022-167730 z 16:INNER CASING OR TUBING(geothermal closed-loapls- '.,4 '4 V.: el 2-Well Construction Permlf#: FROM To - •MAME MR TRICIOsESS MATERIAL list all applicable well congruency'permits(i.e.U/C',Cauay,State. Variance.etc.) h. IL In. 3.Well Use(check well use): ft. ft. In. Water Supply Well: :�i7:SCR1:e:Nf-•..-s r 77 ✓:*::'>;-;rt.. •r,??aa:4is..t ,t:'1es'u,. Eli .te':-;'.;. FROM TO - DIAMETER SLOTSIZF.. THIC NrSS MATERIAL OAgricu(tural: ❑Municipal/Public It; it, in. °Geothermal(Heating/Cooling Supply) (!Residential Water Supply(single) ft ft. In. Olndustrial/Conunercial• °Residential Water,Supply(shared) °litigation - . DWells>100,000 GPD FROM TO MATERIAL . P.MPLACEMENr METHOD&&MOUSr Non-Water Supply Well: 0 ft. 20 ' Grout Poured °Monitoring- °Recovery ft. R. Injection Well: ft. ft. °Aquifer Recharge °Groundwater.Remediation OA uifer Storageand 3191SAND/GRAVEL PACK pfappliephle)':")c.-1 0.0' FT=',;•T ': .,v .cvr-a. 9Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD °Aquifer Test OStormwater Diainage IL ft. °Experitoental Technology °Subsidence Control °C•reothermal(Closed Loop) °Tracer '.'20:DRILLING'.LOG(attach aid ltiooal Weed If necessary)'ii"t141 '-:Oe.":4.'t PROM .TO DESCRIPTION(color.hardness,,otaraca laps grain site,ale.) ❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 n:j 56 - ft. Dirt' 4.Date Well(s)Completed: 6-14-2022 Well ll)t! 93 h' 200, it.. Rock _ Sa.Well Location: Keith Estes n. ft• Facility/Owner Name :Facility IDS(if applicable) R. R. 3473 Storybrook Ln, Sherrills Ford NC 28673 ft. ft. Physical Address,Ciry,'and Zip ft. tt- CataWb8 County Parcel Identifrcatioii No.(PIN) M.Latitude and longitude in degrees/minutes/seeoods or decimal degrees: (if well Geld;one lat/long is sufficient) 22.Cettifcadon: 35' 60.025' .N 081' 04.769' w 7/20/2022 6.Nate)the m'ell(s): 'Permanent or °Temporary iRnature ofCcniticd Well Convector Date By signing Ihisfow',/hereby Aertfr that 0e well(s)vws(were)constructed In accaidunce with . 7.Is this a repair to an existing well:. ❑Yes or ONo ISA NCAC 02C..0/00 or1SA NCAC OW.0200 Well'Construction Standards and that a copy If thi.CM a repairfill oui known well co tit action injimmatian and explain the nature of the of this record Gat been provlderr to She well owner: repair under#21 renwit s cJiion or n the back of th fiirni. 23.Site diagram or additional well details: K.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the sonic You may use the hack of this page to provide additional well construction info construction.only 1 GW-1 is needed. hidicatc TOTALNUMDER of wells (and See Over in Remarks Box).You may also attach additional pages if necessary. drilled: 24.SUBMI1TAL INSTRUCTIONS 9.Total well depth below land surface: 200 (ft.) For multi*Wells list all deptlu idiflereri((ample-3©200'and2©t0d') Submit this GW-1 within 30 days of well completion per the following: 10.Static water level Below top of c• asing: 80 (n) 24a. For All Wells: Original form to Division of Water. Resources (DWR). IIfworc7Jrvel is aboveYdrmR,use"+'• Information Processing Unit.1617 MSC;Raleigh,NC 27699-1617 246.For Injection Wells:Copy to DWR, Underground Injection Control(1UC) I I.Borehole diameter: 6.25 (in) Program,1636 MSC,Raleigh,NC 27699-1636 Air Drilled 12 Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ( auger,mtary,enhle,chT 5 push,de.) county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pprodudna over 100,009 GPD:Copy to DWR,CCPCUA. 13a.Yield(gpm) 50 Method of test: Air Pcrnut Program, 1611 MSC,Raleigh,NC 27699-1611 . 1�I 13b:Disinfection typedHTH Amount: 3/4 cup Form G W-1 North Carol ilia Department of Environmental Quality-Division of Water Resources Revised 6-6.2018