GW1-2021-02640_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 A
FHOM TO DESClllrflON
Well Contractor Name 40 ft• 405 ft'
3254 A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased Wells OR LINER ifa Iicable
Russell Well Drilling, Inc. FROM TO DIA METER THICKNESS MATERIAL
Company Name 0 ft- 62 ft- 6.25 i" SDR21 PVC
16.INNER CASING OR TUBING edthermal closed-loop)
2.Well Construction Permit#: N/A FROM TO DIAMETER TfUCKNESS 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 TTOCKNESS MATERTAL
Agricultural [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential 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 ft Grout Poured
Monitoring DRecovery
Injection Well:
ft. ft.
:)Aquifer Recharge DGroundwater Remediation
19.SAND/G RAVEL'PAC K(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStolrnwater Drainage
ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock rain slrs etc.
Geothermal(Heating/Cooling Cooling Return ;Other(explain under#21 Remazks 0 tt. 57 [t. D I rt
4.Date Well(s)Completed:01-22-21 well ID# 57 ft. 405 1- Rock
5a.Well Location: ft. ft.
Nelson Rogers ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Q l 1I,
470 Roy Rogers Ct., Taylorsville, NC 28681 ft. ft. )pgUnitPhysical Address,City,and Zip ft. ft. DWR sgdjpn
Alexander 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) �V'
ieation•
35' 54.479' N 081' 15.979' W
07-15-21
6.Is(are)the well(s)oPermanent or OTemporary SlFmtureofCertified W 1 Contractor Date
$v signing this form.1 herebv certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill nut known well consnuction information and explain the nature o(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: 405 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells 1W all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
If water level is above casing,use'.+" 1617 Mail Service Center,Raleigh,NC 276994617
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) 10 Method of test: Air 24c.For Water Supply&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 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