GW1-2022-06529_Well Construction - GW1_20220511

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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 60 it. 465
ft• �,
I' 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 It- 67 ft 6.25 SDR21 JPvc
Company Name
16.INNER CASING'ORTUBING eothet•malclosed-loo
2.Well Construction Permit#: 71 5 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
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt fL in.;
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft• ft. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hn ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediatiion
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
)
[]Geothermal FROM To DESCRIPTION
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) color,hardness,soil/mck type, rain size,etc.)
0 It-
62 ft Dirt
4.Date Well(s)Completed: 3-14-22 well ID# 62 ft. 465 ft. Rock
5a.Well Location: ft ft.
Monty & Sharon Poarch Sedgewick Homes ft ft.
Facility/Owner Name Facility ID#(if applicable) ft It.
6022 Sandbar Rd, Granite Falls, NC 28630 ft. ft
fL ft. I!�
Physical Address,City,and Zip
21.REMARKS
Caldwell
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Certification•
35' 49.674' N 081' 20.892' W 4/6/2022
6.Is(are)the well(s): ®Permanent or ❑T
emporary Signature of Certified Well Contractor Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo ISA NCAC 02C.0100 or ISA 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).Ydu may also attach additional pages if necessary.
drilled: 24.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: 465 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
C Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1`� Method of test:Air
13b.Disinfection type: HTH Amount: 1 1/3eup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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