GW1-2021-02575_Well Construction - GW1_20210930

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
3254 A 60 ft. 325 ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for could-cased'wells OR LINER°tf a licabte
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft- 3 f
8 ft- 6.25 SDR21 PVC
Company Name 0 16..INNER CASING OR TUBING eothermalclosed-loo'
2.Well Construction Permit#: n/a 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
rJAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
r 19.SAND/GRAVEL PACK'if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soiltrock to size,etc.
0 ft. 33 ft. Dirt
4.Date Well(s)Completed: -8-2021 we111D# 33 ft. 325 ft. Rock
5a.Well Location: ft. ft.
Andy Taylor ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. l C '101t
6291 Old Laurel Rd, Connelly Springs, NC 28612 f° 1 ft ore"I 9
Physical Address,City,and Zip ft ft. \,NR S$C'YI
Burke ;21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35' 39.275' N 081' 31 .121' w - 9/27/2021
6.Is(are)the well(s): JQPermanent or ❑Temporary ignature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.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: 325 (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')
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
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)
,.1
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r D rI I I ed 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) 100 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018