GW1-2021-00460_Well Construction - GW1_20210210

�Prnt�Form�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor information:
Chris C. Russell 14.WATERZONES-
Well Contractor Name FROM TO DESCIUI'TION
3254 A 100 ft 425
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING`fog ri ulti-cased'wetis OR LINER'ifs livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 103 6.25 In SDR21 PVC
W P# 712 I&INNER CASING OR'TusING-(geothermal closed-loop
2.Well Construction Permit#: tF FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UiC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 1F7R.OSMREENTO DIAMETER SLOT SIZE THICKNESS MATERTAL
Agricultural E]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
IndustriaVCommercial Residential Water Supply(shared) 18.`GROUT R
Irri ation FROM TO MATEAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft' Grout Poured
Monitoring Recovery
Injection Well:
Aquifer Rcchargc [3Groundwatcr Rcmcdiation
19+SAND/CRAVEL=PACK-tf a livable - '
Aquifer Storage and Recovery [3Sallnity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attschsadditlonalsheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,solthock in sirs etc.
0 ft 98 ft- Dirt
4.Date Well(s)Completed: 11-3-2020 wen 1D# 98 tt 425 ft• Rock
5a.Well Location: ft. ft.
Timothy Toomey Randy Simmons ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1690 High Country Rd, Lenoir, NC 28645 ft. ft.
Physical Address,City,and Zip
ft. ft.
Caldwell 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:
35' 53.624' N 081' 40.223' W
6.Is(are)the well(s)OPermanent or Temporary Signahn&f Certified Well Contractor Date
By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 13 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fell out known well construction information and explain the nature of the copy of thiv 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: S B%L17AL INSTRUCTIONS
..�.9 1 .iT t'N'
9.Total well depth below land surface: 42524a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells llvt all depths if different(example-3(a3200'and 2@a 1001 �'
constnrc on to the following:
10.Static water level below top of casing: 100 ft..1 202 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" r n C167 Mall Service Center,Raleigh,NC 276994617
car":
11.Borehole diameter: 6.25 (in.) a ti 41 t 1 4b;dto lniection Wells: In addition to sending the form to the address in 24a
�61`irk
12.Well construction method: Air Drilled �"i,Nv'above,also submit one copy of this form within 30 days of completion of well
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: Air 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 Cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016