GW1-2021-00121_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 100 it- 385 ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Russell Well Drilling, Inc. FROM To DIAMETER TFHCKNESS MATERW
0 ft- 62 ft 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING 'eothermal elosed-loo
2.Well Construction Permit#: 0714W 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): ft ft. in.
17.SCREEN
Water Supply Well: '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft• ft ;n,
❑Industrial/Commercial ❑Residential Water Supply(shared) 718.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
::19.SAND/GRAVEL PACK ifs livable
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'additionid sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0 ft. 57 ft Dirt
4.Date Well(s)Completed: 6-24-2021 well ID# 57 ft 385 ft Rock
5a.Well Location: Pt ft.
Mario Pineda Roy Penley ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
2317 Swain Creek Rd, Jonesville, NC 28642 ft. ft. NOV 9 2021
Physical Address,City,and Zip
ft. ft
Wilkes 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
36' 52.313' N 081' 21.003' w
� 10/12/2021
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified WeV Contractor 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 8No 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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#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: 385 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi[ferent(example-3@200 and 1@100')
10.Static water level below top of casing: 100 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use o ^
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: Air
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) 10 Method of test:Ai r Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: HTH Amount: 1 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018