GW1-2022-07095_Well Construction - GW1_20220801

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contract :Contractor Information
Chris C Russell <14aWATERZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A � so ft- 405 ft• #
fL ft
NC Well Contractor Certification Number .15 OUTER CASING fdk multi casediwells OR-LINER-'if a 'tleable?:
Russell Well Drilling, Inc. FROM TO DIAMETER r THICKNESS MATERIAL
0 ft- 79 ft- 6.25 ! In SDR21 JpVc
Company Name 163NNERCASING'OR
334268 TUBING; 'eottiprmsl'closed=too _. rz3
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction_permits(i.e.UIC,County,State,Variance,etc) fL ft In.
3.Well Use(check well use): ft. ft In.
Water Supply Well: FROM-SCREEN
TO DIAMETER h SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in..
OGeothermal(Heating/Cooling Supply) VIResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) AS.-,"GROUT:
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
OMonitoring ❑Recovery ft fL
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL;PACK?if,a"011ciible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology OSubsidence Control
OGeothermal(Closed Loop) ❑Tracer 20iDRILtiING1OG'stti&%dditiooal0ee6-ifnecessa'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock in size etc.)
0 fL 74 ft- Dirt
4.Date Well(s)Completed: 7-25-22 Well ID# 74 n- 405 tL Grout in
Sa.Well Location: ft ft
Thomas&Lynn Deatherage ft ft 12022
Facility/Owner Name Facility ID#(if applicable) ft. ft 1fffCfA3r�110'1 y!-. .
Ag
167 Rivercliff Dr. Stony Point, NC 28678 ft. ft Dk.YCilt1j0G
Physical Address,City,and Zip fL ft.
Iredell 21REMARKS '(•', ;'.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.CVpfication:
35' 77.916' N 08" 09.781' W - 7/26/2022
6.Is(are)the well(s): 001'ermanent or ❑Temporary Signature o ertified 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 l!lNo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 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).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405 (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3@200'and 2@1001
10.Static water level below top of casing:.60 (fk) 24a. For All Wells: Original form"to Division of Water Resources (DWR),
If water level is above casing,use"+•' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Drilled 24c.For Water Supply and OpeuLLoop Geothermal Return Wells:Copy to the
(Le.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 27699-1011
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018
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