GW1-2021-00019_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
3254A 40 ft 325 rt.
fL ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER if a livable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 80 it- 6.25 in. I SDR21 JPVC
Company Name
13455 16:INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) fL fL in.
3.Well Use(check well use): It. ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) mResidential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 IL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft fL
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK-if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑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)
TO DESCRIPTION(color,hardy soil/racke, in size,etc.)ks) 0 ft. 75 ft Dirt
4.Date Well(s)Completed: 9-23-2021 Well ID# 75 ft 325 fL Rock
5a.Well Location: ft. ft.
Lisa Herman It. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
NOV
754 Long Shoals Rd, Lincointon, NC 28092 ft. ft.
Physical Address,City,and Zip ft. ft. DVVR SECTION
Gaston ;21.REMARKS i 1 I
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:
35' 22.488' N 081' 153.459' W �.�a ectO
� 10/12/2021
6.Is(are)the well(s): dPermanent or ❑Temporary Signs dottne f Certified Wel ontractor Date
By signing this form,I hereby certify that the well(s)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#2I 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: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
If 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: Air Dulled
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) uTu Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: H I n Amount: 1 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018