GW1-2021-01593_Well Construction - GW1_20210419

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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 I DESCRIPTION
Well Contractor Name
3254 A 60 ft- 205 ft
f[. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`.wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 95 ft- 6.25 in SDR21 I PVC
312354 f 16.1NNER CASING'OR TUBING '(geothermal closed-loopy
2.Well Construction Permit#: FROM TO DIAMETER TIHCKN`ESS MATERIAL
List all applicable well construction permits 4.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1F�ROSM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. in.
Industtial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
Monitoring Recovery
injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [i Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)'
FROM TO DESCRIPTION color,hardness soll/rock rain size etc.
Geothermal eatin Coolin Return) ;Other(explain under#21 Remarks
0 It. 90 f- Dirt
4.Date Weu(s)Completed:3-23-2021 Well ID# 90 ft. 205 ft. Rock
5a.Well Location: ft. ft.
Peter & Denise Gibbons ft. ft.
Facility/Owner Name Facility m#(if applicable)
130 Blue Spruce Lane, Cleveland, NC 27013
Physical Address,City,and Zip
ft. ft. IQ
redell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35' 42.545' N 080' 47.284' W
3-23-2021
6.Is(are)the well(s)OPermanent or OTemporary SiFiarure ofCertified-WeITContiractor Date
By signing this form.I herebv certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or ONo with I5A NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has heen 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 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: 205 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3L200'and 2L100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 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:
(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) 20 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sclyding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1/2 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