GW1-2021-02153_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 -;
To
Well Contractor Name FROM DrSCRLP"ION
40 ft. 425 ft.
3254 A `11� 0 9 2021
ft. ft.
NC Well Contractor Certification Number unit IS.OUTER CASING for multi-cased wells OR LINER if a livable
Russell Well Drilling, Inc, tDfGI�,3t'Ion prot;e�stng FR(IM TO DIAMETER THICKNESS MATERIAL
_ tat��g'Y'on 0 ft. 75 ft. 6.25 ln. SDR21 I PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: n/a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: ,-1F7ROSM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
IndustriaVCommercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 Grout Poured
Monitoring ORecovery
Injection Well: it ft
Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK ifa livable
Aquifer Storage and Recovery OSahmty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock rain size etc.
Geothermal(Heating/CoolingReturn) 'Other(explain under#21 Remarks 0 ft. 70 ft' Dirt
4.Date Well(s)Completed: 5-25-21 Well ID# 70 it 425 " Rock
ft. ft.
5a.Well Location:
Sam Walker ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2736 Falls Rd, Moravian Falls, NC 28654 ft. ft.
Physical Address,City,and Zip ft. ft.
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C rtification:
36' 04.355' N 081' 13.182' W /
91L.J 6-25-21
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or J3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thiv is a repair,fill out known well convtruction 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200'and 2@100') construction t0 the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1.+11 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this fonts 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
f
13a.Yield(gpm) 30 Method of test: Air Drilled 24c.For Water Supply At Injection 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 1/3 cup completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016