GW1-2021-08139_Well Construction - GW1_20211109

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
3254 A so fL 425 h•
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER If a licable .
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft 102 IL 6.25 In SDR21 JPvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 794 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) g ft• ;a,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Grout Poured
❑Monitoring ❑Recovery ft. fL
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 f• 97 fL Dirt
4.Date Well(s)Completed: 8-31-2021 well ID# 97 fL 425 'L Rock
5a.Well Location: fL ft.
Brent Stamey Todd Triplett It. fL
Facility/Owner Name Facility ID#(if applicable) ft. fL _
1914 Windy Hill Place, Lenoir, NC 28645 ft. fL NOV 9 2021
Physical Address,City,and Zip ft. R•
Caldwell 21.REMARKS nWH SECTION
County Parcel Identification No.(PIN) INFORMATION PROCESSING UNi
II
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35' 53.217' N 081' 40.800' W � )e,,
9/28/2021
6.Is(are)the well(s): Iftermanent or ❑Temporary Signature of Certified Well Nntractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,,1 Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ai Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 1 1/3 cu p60
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018