GW1-2022-08760_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell A4.WATER ZONFS
FROM TO DESCRIPTION
Well Contractor Name
100 "It- 265 It
3254 A ft. ft.
NC Well Contractor Certification Number
is.OUTER CASING-(fdrIald dells)PB LINER"ffaIijtIcabIe)-,-,.-1
Russell Well Drilling, Inc. FROM To DIAMETER IWMATERIAL
i
Company Name 0 ft- 191 it- 16.25 1 1-- ISDR21 JPVC
16.INNER;CASING OWT, ING
2.Well Construction Permit#:W502 FROM TO DIAMETER. Tfuclums 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: t7 SCREEN i::1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipaVPublic It• ft. in.
[)Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single) • in.
01ndustrial/Commercial 0 Residential Water Supply(shared) 18.:GROUT:,-.
01rrigation OWells>100,000 GPD FROM TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 Grout Poured
01vionitoring ORecovery ft. ft.
Injection Well:
fL ft
OAquifer Recharge' OGroundwater Remediation 19.SAND/GRAVELTACK(iftipplie.lible),---
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT MLETHOD-
OAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(itfivih ifilditiodlit sheets'if necessar�)
oGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO _ DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft' 86 ft- Dirt
4.Date Well(s)Completed: 8-1-22 Well ID# 86 ft- 265 ft- Rock
5a.Well Location: ft. ft.
Bobby & Elaine Norton
Facility/Owner Name Facility ID#(if applicable) ft. ft
680 Church Rd, Taylorsville, NC 28681 ft. ft. SEP 0 9 2022
Physical Address,City,and Zip ft. fL
Alexander 21.REMARKS n7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
22 C rtifi d
(if well field,one lat/long is sufficient) ;; n:
35'90.642' _N081 25.344' 8/4/2022
6.Is(are)the well(s): GlPermanent or OTemporary Sign fure of Certified Well Contractor Date
By signing this form,I hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: E]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 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-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: 265 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdzfferent(example-3@200'and 2@100�
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: -YL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
II.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:Air Drilled 24c.For Water Supply and Open-Loop
-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 Wellsproducing over 100,000 GP Copy to DWR,CCPCUA
Permit Program,1611 i C, !i
Raleigh,NC 27699-1611
13a.Yield(gpm) 100 Method of test:Air
13b.Disinfection type: HTH Amount: 1/2 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018