GW1-2022-06530_Well Construction - GW1_20220511

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 70 ft 425 ft.
ft I M
NC Well Contractor Certification Number
15;OUTER CASING for multi-cased;wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER' THICIQVESS MATERIAL
Company Name 0 ft- 93 ft 16.25 in- ISDR21 JPVC
Q O
16.1NNER CASING OR TUBING eothermafclosed-too
2.Well Construction Permit#: 828 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.i
❑Geothermal(Heating/Cooling Supply) mResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lni 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 a licable
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRILLING LOG(attachadditional sheets if necessary)
❑ FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 " 88 ft Dirt
4.Date Well(s)Completed: 2-1 0-22 Well ID# 88 ft. 425 ft- Rock
5a.Well Location: ft ft
Vogel Builders Co. ft ft
Facility/Owner Name Facility fD#(if applicable) M ft MAY
Y
Lot 529 Scenic Vista Trail F1
Physical Address,City,and ZipDWORM
ft. ft.
Caldwell 2L REMARKS
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Ce 'ication:
35' 91 .064' N 081' 66.481' W - 4/6/2022
6.Is(are)the well(s): ZPermanent or ❑Temporary Sign a of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)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 of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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: 425 (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 70 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
I
11.Borehole diameter:6.25 (in.) 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Air Drilled
12.Well construction method: Air 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) 10 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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