GW1-2021-02114_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES ,
,,ECEN 100 ft. ft
245 DhsCltll'rLON
Well Contractor Name HCOM. 'to
3254 A
ft. ft.
(�
NC Well Contractor Certification Number JUL O u 2021 15.OUTER CASING for multi-cased welts OR LINER ifa llcable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
unit 0 ft. 153 ft 6.25 i" SDR21 PVC
Company Name
DW R$GCIIOn 16.INNER CASING OR TUBING eathermal closed-loop)
2.Well Construction Permit#: 765 FROM TO DIAMETER I TtUCKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: '.1R.OSCREE F•7 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
_ 1rri atlon FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
Monitoring Recovery
Injection Well:
_Aquifer Recharge 13Groundwatcr Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESCRTPTTON color,hardness soturock type,grain size ctc.
0 1t• 148 ft Dirt
4.Date Weu(s)Completed:4-11-21 Well ID# 148 ft 245 ft Rock
5a.Well Location:
Terry & Debra Dunn Moss Marlow ft. ft.
Facility/Owner Name Facility lDlt(if applicable)
5825 Box Turtle, Lenoir, NC 28645
Physical Address,City,and Zip ft. ft.
Caldwell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification'
35' 852.890' N 81'608.110' W
�e�ti?iyt�Cl �- /U'2/
6.Is(are)the well(s)oPermanent or OTemporary 'Mgilatke of Certified Well Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well comtrucdon information and explain the nature of the copy 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftlifo-ent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1/2 Cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016