GW1-2021-02792_Well Construction - GW1_20210805

''Print Form T
WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 100 ft• 645
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 It- 74 ft- 6.25 in- SDR21 PVC
07rZ7 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIA[.
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: FR• MSCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
Monitoring ORecovery
injection Well:
ft. ft.
Aquifer RechargeGroundwatcr Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSaLinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach addittonil sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness soil/rock type,grain size etc.
0 ft 69 "L Dirt
4.Date Well(s)Completed: 6-28-21 Well ID# 69 ft 645 ft. Rock
5a.Well Location: ft. ft.
Mark & Shelia Bishop Roy Penley
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lot#177 Casey Mtn. Rd, Wilkesboro, NC 28625 ft. ft.
Physical Address,City,and Zip ft. ft. AUG
Wilkesboro 21.REMARKS
County ParelIdentificationNo.(PIN) InfOi(Il0tI0i1 r0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36' 32.675 N 081' 21.425 w ,
2ee� 7-20-21
6.Is(are)the well(s)oZi Permanent or Temporary Signature of Certi ed Well Contractor 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: []Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well comtruction information and explain the nature of the copy of this record has been provided to the well owner
repair under#11 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-I 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: 645 (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)200'and 2(d100') construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this fonin 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) 3 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 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