GW1-2022-03823_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD(GW-1) For Jnternal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 100 ft. 305 ft• i
ft. ft.
NC Well Contactor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 72 ft- 6.25 ' in. SDR21 JPVC
Company Name
7 16.INNER CASING ORTUBING(geothermal closed-loop),
2.Well Construction Permit#• " 77 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.SCREEN'
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 % Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. M
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary).
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM
ft. 67 ft Dirt
4.Date Well(s)Completed: 01-28-2022 Well ID# 67 ft• 305 ft. Rock
5a.Well Location: ft. ft
Raul Hernandez ft rt.
Facility/Owner Name Facility ID# ifa applicable) ft. ft
Y ( PP ) r 1J� I
3025 Hartley Kincaid Place, Lenoir, NC 28645 ft. ft -d
Physical Address,City,and Zip ft. ft. APR
Caldwell 21.REMARKS'
County Parcel Identification No.(PIN) If
t1EL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
1Ji� SvFia ��
(if wcll field,one Iattlong is sufficient) 22.Certification:
35' 97.679 N 081' 48.103' W N � 2/8/2022
6.Is(are)the well(s): [♦Permanent or ❑Temporary Signa�m a of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 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 ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis farm.
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: 305 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 00 (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 toDWR,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
(Le.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 Liver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 5 Method of test:Ai r i
13b.Disinfection type: HTH Amount: 2/3 cup
P
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources l� Revised 6-6-2018
I