GW1-2021-03338_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
Well Contractor Name FROM To DESCRIPl-ION
3254 A 60 ft 265 ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased veils OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 101 ft 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 311352 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TTIICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fa ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
7.1 Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 ft Grout Poured
Monitoring ;Recovery
Injection Well:
Aquifer Recharge OGroundwatcr Rcmcdiation 19.SAND/CRAVEL PACK if applicable)
_ Aquifer Storage and Recovery OSalmlty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal (Heating/Cooling Return Other(explain under 421 Remarks FROM TO DESCRIPTION color,hardness soil/rocktype, rain size etc.
0 ft- 96 rt. Dirt
4.Date Well(s)Completed:4-20-21 Well ID# 96 "' 26511• Rock
5a.Well Location: ft. ft. iP'
Jeremy Plyler ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
103 Tucker Rd, Statesville, NC 28677
Physical Address,City,and Zip ;p0 pIpCe
Iredell 21.REbIARKS
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' 42.859' N 080' 50.445' w
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6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.1 hereblv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
!f this is a repair,fill out known well construction information and explain the nature of the copy of dds 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:
R.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-I 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 ifdij]erent(example-3L200•and 2L100') 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 1.", 1617 Mail Service Center,Raleigh,NC 276994617
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: hi addition to scliding 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