GW1-2022-06364_Well Construction - GW1_20220705

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 100 ft, 385 ft,
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Russell Well Drilling, C FROM TO DIAMETER THICKNESS MATERIAL
0 ft.
90 ft 6.25 in- ISDR21 PVC
Company Name
0614 W 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 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 Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soiltrock typq grain size,etc.)
0 fc. 85 ft. Dirt
4.Date Well(s)Completed: 4-20-2022 Well EM 85 f` 385 ft' Rock
5a.Well Location: ft. ft.
Sharon Parker Doug Coffey Const. LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Price Rd ft. ft.
Physical Address,City,and Zip ft. ft.
Wilkes 21.REMARKS
County Parcel Identification No.(PIN) J U L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cfwell field,one lat/lon sufficient
g�is ) 22.Certification:
36' 12.235' N 081' 15.6581 W
6/1/2022
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or C1No 1 SA NCAC 02C.0100 or I5A 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 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 I 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: 385 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdifferent(example-3@200'and 2@100D
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 level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
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) 15 l._1 Method of test: i r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 cap
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018