GW1-2021-00985_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form
1.Well Contractor information: w tP'
Chris C. Russell "
1a:WATER zoNEs" .,-
Well Contractor Name FROM 'to DESCRIPTION
9 2021 40 ft• 345
3254 A Ge�S�n9 Unit ft. ft.
NC Well Contractor Certification Number i� 3t1On p�� On 15.FROM
CASING for munllti-Cased Hells OR'L11 R S a It able) AL
Russell Well Drilling, Inc. �n Ire pVdR crTHI
Company Name
0 ft, 105 ft- 6.25 '" SDR21 I PVC
W457 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
Agricultural [DMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) ft. ft
Industrial/Commercial [)Residential Water Supply(shared)
18.GROUT
hli ation FROrd I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Grout Poured
Monitoring [)Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK rf a licablc
Aquifer Storage and Recovery [3Salnuty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return y Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock rain slrc ctc.
0 ft- 100 ft- Dirt
4.Date Well(s)Completed:03-22-2021 Well M# 100 ft. 345 f• Rock
Sa.Well Location: ft. ft.
Krystal Broyhill Luper ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
222 Powell Rd, Taylorsville, NC 28681 ft• ft.
Physical Address,City,and Zip ft. ft.
Alexander 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.Cc tifi ation:
35' 58.557' N 081' 08.587' w
ell 03-25-2021
6.Is(are)the well(s)oX Permanent or OTemporary Signature ofCcrtified a ontractor 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 E)No with I5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well conenuctlon information and explain the nature of the copy of this 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 Welts 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: 345 (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffia•ent(example-3(a3200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfivater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
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:
(Le,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 Suovly Ae 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 ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016