GW1-2022-06363_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 45 ft- 285 rt.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 63 ft- 6.25 in SDR21 JPVC
Company Name
0602 W 16.INNER CASING OR TUBING(eotlnermal closed-loo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. in,
ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) 9Residential Water Supply(single) ft. ft. in.
01ndustrial/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 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 Retum) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soilfrmk rain size,etc.)0 f" 58 ft. Dirt
4.Date Well(s)Completed: 5-4-2022 Well ID# 58 ft. 285 ft. Rock
5a.Well Location: ft. ft.
Dogmara Rodriguez Anthony Kline fL ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
Wildcat Rd, Wilkesboro, NC 28654 ft. ft.
Physical Address,City,and Zip ft. ft.
Wilkes 21.REMARKS `•_;k -1 r ,5 i )1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JUL 6 202?
(ifwell field,one lattlong is sufficient) 22.C ification: .r
36' 08.221' N 081' 10.410' W �'''''``= ;l.•:;a
/2022
6.Is(are)the well(s): RPermanent or ❑Temporary Signature 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 LhNo 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 a-on the back ofthis fonn.
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: 285 (ft) Submit this GW-1 within 30 days of well completion per the fallowing:
For multiple wells list all depths iftli ferent(example-3(�00'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater lave!is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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) 20 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018