GW1-2021-02682_Well Construction - GW1_20210805

r ��Print Form
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- 465 ft
ft. tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Itcable
Russell Well Drilling, Inc. FROM TO DIAhETER THICKNESS MATERIAL
Company Name 0 ft. 70 ft- 6.25 in SDR21 I PVC
25779 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TMClrn-ESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: -
FROM TO DIAMETER SLOT SIZE TRTCKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/cooling Supply) OResidential Water Supply(single) ft. ft. irL
Industrial/Commercial DResidential Water Supply(shared) iR.GROUT
71 Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Grout Poured
Monitoring Recovery
Injection Well:
ft. tt.
_Aquifcr Recharge Groundwater Rcmcdiation
19,SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D'i Stormwater Drainage
Experimental Technology OSubsidence Control ft• ft•
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRTPTTON color,hardness solUruck rain size etc.
!Geothermal(Heating/Cooling Return ;Other(explain under#21 Remarks 0 tt. 65 ft' D I rt
4.Date Well(s)Completed: 5-11-21 Well ID# 65 ft. 465 ft. Rock
5a.Well Location:
Jay & Julie White Spivey Constr. ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. tt. ,i 0
1157 Winding Creek Way, Lenoir, NC 28645 ft. it. ocess
Physical Address,City,and Zip
Caldwell 21;REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
35' 909.800' N 081' 979.930 W /, .4—
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.1 herehv cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• E)Yes or M No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:
A.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: 465 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a)100'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (ft.) 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 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 Suaoly&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 1/3 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