GW1-2022-01777_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254A 80 ft• 245 ft.
ft. ft
NC Well Contractor Certification Number 15:OUTER;CASING for multi-cased wells ORLINER if a "7icable;
Russell Well Drilling, Inc. FROM TO DIAMETER TLHCIQYESS MATERIAL
0 ft 196 ft- 16.25 1n SDR21 ImVC
Company Name
-IC HINER CASING OR TUBING `eothermal closed-too
2.Well Construction Permit#: 876 FROM I TO I DIAMETER TIHCKNESS 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`,:19:;SAND/GRAVEli PACK,if applicable)
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if uecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock in size,etc.
0 ft. 91 ft Dirt
4.Date Well(s)Completed: 01-26-2022 Well # 91 ft- 245 fL Rock' a
ID 3
5a.Well Location: ft. ft
Nancy Honeycutt `t `t
Facility/Owner Name Facility ID#(if applicable) ft It. 1f fiOfikiOLL'ftV ul
1227 Honeycutt Lane, Lenoir, NC 28645 ft ft.
Physical Address,City,and Zip
Caldwell 21.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:
35' 92.729' N 081'40.582' W &'- , 2/3/2022
6.Is(are)the well(s): ®Permanent or ❑Temporary Sigirature of Certified Well 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 [INo 1 SA NCAC 02C.0100 or 15A]VCAC 01C.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#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 (fL) 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 1@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: 80 (ft) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" j
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) Method of test: i r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/2 cup I
s
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resouu rc es Revised 6-6-2018
I