GW1-2022-07093_Well Construction - GW1_20220801

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14:WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name 98 R• 245 ff,
3254 A ft fL
NC Well Contractor Certification Number 15;OUTER CASING for,rrialtitased wells)OR LINER it a 'l icahle
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 98 tt 6.98 ISDR21 JPVC
Company Name ''1
• 330018 6.1:NNERGASING'OR'TUBING( eothermalclo's"ea-loo r
2.Well Construction Permit#. FROM TO DIAMETER THICKNESS MATERIAL
Cut all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft.
Water Supply Well: FROM E TO DIAMETER..':. SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public IL ft. in.
❑Geothermal(Heating/Cooling Supply) IfResidential 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 ft• 20 ft. Grout
❑Monitoring ❑Recovery ft. ft.
Injection Well:
IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19;'SAND/GRAVEL PACKi if s' ticahle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft M
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attachodditional sheets.i6necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock type,grain size etc.
0 ft 93 fL Dirt
4.Date Well(s)Completed: 7-19'22 Well ID# 93 ft- 245 ft- Rock
5a.Well Location: fL ft RE E t
Jeff Cash fL fL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
120 Cash Lane, Statesville, NC 28677 ft ft fmawn f°G ']g 'o(
Physical Address,City,and Zip ft. rL
Iredell 21.REMARKS.5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one IaUlong is sufficient) 22.Ceram'to
35' 44.697' N 080' 49.687' W �/ 7/27/2022
6.Is(are)the well(s): OPermanent 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 InNo 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.0100 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 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-i 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: 245 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3Q200'and 2 100)
60 24a. For All Wells: Original fo4m to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617!MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (ln.),. program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.For Water Supply and Operi-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
Permit Program,1611 MSC,Raleigh,13a.Yield(gpm)25 Method of test:Ai r NC 27699-1611I
13b.Disinfection type: H T H Amount: 3/4 cup
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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