GW1-2021-03287_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 60 ft 265 ft.
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING`for multi-cased wells OR LINER ifa licable
Russell Well Drilling, Inc. FROM TO DIA METER THICKNESS MATERIAL
Company Name 0 ft- 187 h 6.25 SDR21 I PVC
16.INNER CASING OR TUBING.(geothermal closed-loo'
2.Well Construction Permit#: 720 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN ' -
pp y FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
:)Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT
1r71 atiou FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 R Grout Poured
Monitoring ORecovery
injection Well:
:]Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)' =
FROM TO DESCRIPTION color,hardness solltrock rain size etc.
Geothermal(Heating/CoolingReturn) ,Other(explain under#21 Remarks 0 ft. 82 f� Dirt
4.Date Weu(s)Completed: 5-14-21 Well ID# 82 ft• 265 f1. Rock
5a.Well Location:
Johnathan Moore Sedgewick Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Blue Creek Rd, Lenoir, NC 28645
Physical Address,City,and Zip ft. ft.
Caldwell 21 REMARKS
151 Grma
County Parcel Identification No.(PIN) PAIR S8d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtifreation:
35' 58.406' N 081' 27.215' W
11 A) )V"A�a� 05-25-2021
6.Is(are)the well(s)oPermanent or OTemporary Srgna a of Certified Well Contractor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or E)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 c•onrir•uc•tion information and explain the nature of the copy of this record hat been provided to the well owner.
repair under#2i 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 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: 265 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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 Iniection 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) 15 Method of test: Air 24c.For Water Supply&Iniection 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: 2/3 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