GW1-2021-01588_Well Construction - GW1_20210309

I Print Form_ ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATERZONEs
Well Contractor Name FROM TO DESCRY'/'ION
3254 A 60 ft 525 ft-
ft. [t.
NC Well Contractor Certification Number 15.fOUTER CASING for rnuiti-cased wells OR WNER ifa livable
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 it. 75 fl 6.25 '" SDR21 PVC
0418 W 16.INNER CASING OR'TUBING 'eothermal etosed-lob
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1 .
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATEAiAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ;n
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 t1 20 ft Grout Poured
Monitoring E3Recovery ft. ft.
injection Well: ft. ft
:)Aquifer Recharge E)Groundwatcr Rcmcdiation
19.,,SAND/CRAVELPAGIC.6fa"1ivable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attac'additional sheets if oecessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soll/rock type,grain size etc.
o �• 70 �• Dirt- .
4.Date Wells)Completed:2-10-2021 _weu ID# 70 It- 525 ft- ROCk
5a.Well Location: ft. fL
Pete Lucarelli
Facility/Owner Name Facility ID#(if applicable)
1660 Walshtown Rd, Boomer, NC 28606
Physical Address,City,and zip ft' RWnrrgnlinn PrOcessing Unit
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36' 05.403' N 081' 14.970' W ()� -l9 2021
6.Is(are)the well(s)oPermanent or []Temporary Si ure of Certified Well Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information d explain the nature of the copy of dtlr 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:
A.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test- Alf 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 2/3 cup completion of well construction to the county health de ent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016