GW1-2021-01594_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: _
Chris C. Russell a.WATER ZONES
FROM TO DESCRUTION
Well Contractor Name 80 ft 445 ft•
3254 A
ft. ft.
NC Well Contractor Certification Number AS.OUTER CASING'for multi-easedrWells)OR-LINER ifa licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 f`• 80 ft- 6.25 'n SDR21 I PVC
311932 16.INNER CASING OR TUBINGclosed-loop)eothermal
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Q.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
water Supply well: FROME TO DiAMETERt SLOT SIZE THICKNESS MATERIAL
Agricultural ['Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) is.GROUP
Geothermal
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 13Groundwatcr Remcdiation
19:$ANDlCRAVEL PACK'ifa "liceblc
A[Geothermal
uifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test 13Stormwater Drainage ft. ft.
erimental Technology Subsidence Control
(Closed Loop) 1I Tracer 20 DRiLLI�NG LOG attach additional sheetsIf necessarthermal eatin Coolie Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soiltrock rain size,eta
0 fL 75 ft- Dirt
4.Date Well(s)Completed: 1-19-21 Well ID# 75 f` 445 1- Rock
ft. ft.
5a.Well Location:
Eddie Dellinger Nelson Dellinger ft. ft.
Facility/Owner Name Facility ID#(if applicable)
2586 Buffalo Shoals Rd, Statesville, NC 28677 ft. ft.
Physical Address,City,and Zip
ft. ft.
Iredell 21.REMARKS m .
County Parcel Identification No.(PtN)
�i. �i'd Y 4y•r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tattlong is sufficient) 22.Certification:
35' 43.850' N 080' 59.361' W
6.Is(are)the well(s)oPermanent or OTemporary of Certified Well Contractor Dace
By signing this form.i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or R)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis iv a repay,fill out known well commuction information and ezplain 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 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 445 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(a1100') construction to the following:
10.Static water level below top of casing:80 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 4 Method of test: Air 24c.For Water Supply&Injection 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. s
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016
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