GW1-2022-03815_Well Construction - GW1_20220404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft- 585 ft.
ft. ft.
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 92 ft 6.25 SDR21 JPVC
Company Name
16:
323166 INNER CASING OR TUBING(geothermal closed-loop)'
2.Well Construction Permit#: FROM I TO DIAMETER I 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. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) [EResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ,
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type in size,etc.)
0 ft. 87 ft. Dirt
4.Date Well(s)Completed: 01-14-2022 well ID# 87 ft. 585 rt• Rock
5a.Well Location: ft ft
David M. Honeycutt ft. fr.
Facility/Owner Name Facility ID#(if applicable) ft ft.
116 Gradyrock Dr, Statesville, NC 28677 ft. ft.
Physical Address,City,
Ys,.t and Zip ft. ft. �a�'���-�' dt"�N�
Iredeii -21.REMARKS .County Parcel Identification No.(PIN) APR R` ��4 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'M
(if well field,one IaVlong is sufficient) 22.Certification: . ut.
nruvli�l�1,j�,{I
35' 42.032' N 080' 58.845 W 74MI3/15/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Si c ofCertified Well Contractor Date
By signing this form,I hereby certijy that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 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: 585 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100)
80 24a. For All Wells: Original form,to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) 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)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drilled
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) 2 Method of test:Air Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resoarcesi Revised 6-6-2018