GW1-2021-00984_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: t •
Chris C. Russell 1.
14.,WATER ZONES
Well Contractor Name FROM To DESCRIPTION
3254 A �� 19 20 L� 4,o ft• 345 ft'la
eS51n9 Unit rt. fr.
15.Russell Well Drilling Inc. ant°I�3pWR S�Crp11 FRCMirrE TO R CASING for mu0l i-wA�IIE d Hells F.
ORNIChT tLSS a It MATERIAL
Company Name 0 ft. 105 ft. 6.25 i"• SDR21 PVC
W457 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER TFHM*M MATERIAL
List all applicable well construction permits li.e.U1C,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 TRTCKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft, in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared)
18:GROUT
hTl atiou FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
Monitoring DRecovery
Injection Well: ft ft
Aquifer Recharge OGroundwatcr Rcmcdiation 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) OTracer 20.DRUA INGLOG attach additional sheets if necessary)
Geothermal eatin Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solUrock rain sine etc.
0 ft• 100 ft- Dirt
4.Date Well(s)Completed: 03-22-2021 Well ID# 1001- 345 ft- Rock
Sa.WellLocation: ft. ft.
Krystal Broyhill Luper
Facility/Owner Name Facility ID#(if applicable)
222 Powell Rd, Taylorsville, NC 28681
Physical Address,City,and Zip
ft. fr.
Alexander 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 22.Ce tiff ation•
35' 58.557' N 081' 08.587' W
03-25-2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified WeIrContractor Date
By signing this form.I herebv certify that the mell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or O No with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
lfthis is a repair,ftll out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well mvner.
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-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: 345 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use +" 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) 10 Method of test: Air 24c.For Water SUDDIV&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: 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