GW1-2021-00043_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) iFor Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
So rt. 245 ft•
3254 A
ft ft.
NC Well Contractor Certification Number Inc. 15:OUTER CASING for multi�ased wells OR LINER if a livable
Russell Well Drilling, C FROM TO DIAMETER THICKNESS MATERIAL
0 f4 36 ft- 16.25 i" SDR21 JPVC
Company Name
15378 I&INNER CASING OR TUBING'(geothermal closed-Imp)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17rSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It. in.
❑Geothermal(Heating/Cooling Supply) IEResidential Water Supply(single) ft. g• in.
❑industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 It- Grout Poured
❑Monitoring ❑Recovery ft. ft.
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 ft. ft.
❑Experimental Technology ❑Subsidence Control ft. N.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION eotor,hardness,soil/rock type,grain size etc.
0 31 ft Dirt
4.Date Well(s)Completed: 9-27-2021 Well ID# 31 f° 245 k• Rock
5a.Well Location: ft. f.
Jayson Randall Sedgewick ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. _.,.
5854 Gilbert Hilton Rd, Vale, NC 28168 ft. ft. NUV2021
Physical Address,City,and Zip ft. ft
Lincoln 21s REMARKS OWK SECTION
nl PROCESSING UW
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.C fication:
35'33.466' N 081' 21 .464' W 10/5/2021
6.Is(are)the well(s): QPermanent or ❑Temporary Signature of Certified Well ColWactor 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 Ls 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#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 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: 245 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdifferent(example-3@200'and 2@100�
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
f 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)
Air Drilled Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 Wm) 60 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 2/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018