GW1-2021-02559_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM TO DESClurrloN
Well Contractor Name 50 ft- 365 ft
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 61 ft- 6.25 in- SDR21 PVC
49227 16.INNER CASING OR TUBING &othermal closed-loop)
2.Well Construction Permit M 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.
Water Supply Well: 17fSCREEN
FROM 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 DResidential Water Supply(shared) 18.GROUT
_ ---
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ff• Grout Poured
Monitoring ;Recovery
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Rcmediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSaLinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStorinwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer ;20.DRILLING LOG attach additional sheets if necessary),
FROM TO DESCRIPTION color,hardness soil/rack c rain siu etc.
Geothermal(Heating/CoolingReturn i-_Other(explain under 421 Remazks) 0 it. 56 ft' Dirt
4.Date Well(s)Completed:4-21-21 Well ID# 56 ft• 365 ft. Rock
5a.Well Location: ft. ft.
Loy W. Hoyle J & N Builders ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
Pressley Huffman Rd, Connelly Springs 28612 ft. ft.
Physical Address,City,and Zip ft. ft. 04
Burke 21.REMARKS
County Parcel Identification No.(PIN) `n{'GJ 0k
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, ti teation:
35' 37.777' N 081' 30.323' W
6.Is(are)the well(s)OPermanent or OTemporary Srgnature of Certified el ontractor 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: E)Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction 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-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: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiflerent(example-3(N200'and 2(a)100') Construction to the following:
10.Static water level below top of casing: 50 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 Infection Wells: In addition to sending the form to the address in 24a
Air 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) 12 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 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