GW1-2021-04257_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 DESCRIPTION
Well Contractor Name 40 ft 795 ft.
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lleable
Russell Well Drilling, Inc. FROM TO DIA�t'TER THICKNESS MATERIAL
Company Name 0 ft. 52 ft- 6.25 SDR21 PVC
0472 W 16:-INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: RFROM
TO DIAMETER TtICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
Industriavcommercial Residential Water Supply(shared)
Irrigation TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
Monitoring DRecovery
Injection Well:
Aquifer Recharge OGroundwater Rcmcdiation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRMLINC LOG attach additional&beets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft• 47 It- Dirt
4.Date Well(s)Completed:2-8-2021 Well ID# 47 ft• 795 f• Rock
5a.Well Location: ft. ft.
Alexandra Azevedo Doug Coffee ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. G a^•�vn9 '
1234 Thankful Church Rd, Boomer, NC 28606
Physical Address,City,and Zip
Wilkes 21.REI%ARKs
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:
36' 00.065' N 081' 18.254' W ,
6.Is(are)the well(s)oPermanent or OTemporary gnature ofCertiffed Well Contractor Date
By signing this form.I hereby eeriifv that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: n Ves or ONo with 15A NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well cones-action 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:
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 1 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: 795 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells MI all depths ifdii ferent(example-3@200'and 2(d)100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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) 60 Method of test: Air 24c.For Water Supply&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: 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