GW1-2021-02655_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Russell 4.WATERZONES'
Well Contractor Name FROM TO DESCRIPTION
80 ft. 265 ft
3254A
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a licable
Russell Well Drilling, Inc. FROM T( DINIIETER THICKNESS MATERIAL
Company Name
0 ft 41 ft- 6.25 in SDR21 PVC
W464 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• Grout Poured
Monitoring DRecovery ft. ft.
injection Well:
tt. ft.
_Aquifer Recharge Groundwater Remcdiation
19.SAND/CRAVEL PACK if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
!Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology oSubsideTice Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRrPTiON cc ar,hardness soll/rock rain sirs etc.
Geothermal satin Coolin Return) Other(explain under#21 Remarks) 0 ft' 36 ft' Dirt
4.Date Well(s)Completed:6-15-21 Well ID# 36 ft. 265 ft. Rock
5a.Well Location: RECEIVED
David Garrett, 11 ft. f
Facility/Owner Name Facility lD#(if applicable) ft. ft.
1705 Poplar Springs Rd. Taylorsville, NC 28681 rt. ft. .
Physical Address,City,and Zip
ft. ft. Information Processing Unit
Alexander 21.REMARKS MRSeciinn
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. ertifieation:
35'58.735' N 081' 00.745' W
7-14-21
6.Is(are)the well(s)OPermanent or OTemporary gnature of Certified VNI Contractor Date
By signing this form.I herebv 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 02C.0200 Well Construction Standards and that a
ifthis is a repair,Jill out known well construction information and explain the nature rlthe 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijirent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 80 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.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 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) 100 Method of test: Air 24c.For Water Supply&Infection 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: 2/3 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