GW1-2022-01204_Well Construction - GW1_20220103

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 40 260 ft. ft.
fL 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 TIIICKNESS MATERIAL
0 ft. 97 ft- 6.25 SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 32031 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc) ft. fL in.
3.Well Use(check well use):
ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. fL in.
❑Geothermal(Heating/Cooling Supply) [AResidential Water Supply(single) ft. ft. in.
❑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 rt• 20 ft Grout Poured
❑Monitoring ❑Recovery
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL A ETHOD
❑Aquifer Test ❑Stormwater Drainage fL fL a -1
❑Experimental Technology ❑Subsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets sa
FROM TO DESCRIPTION color,hardness,so
rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2] Remarks) ° ft- 92 fL Dirt
4.Date Well(s)Completed: 1 2-2-2021 Well ID# 92 ft- 260 tt• Rock 1PO r t
5a.Well Location: ft ft
Jeremy Plyer fL fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
109 Tucker Rd, Statesville, NC 28677 ft. ft.
Physical Address,City,and Zip ft. ft.
redell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one IaUlong is sufficient) 22. ification
35'42.868' N 080' 50.418' W - 12/17/2021
6.Is(are)the well(s): IiaPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this form,I hereby cerufi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 01C.0100 or ISA 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-I 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: 260 (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')
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)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air 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)40 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 2/3 cup
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018