GW1-2022-08790_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
50 ft- 145 ft-
3254 A IL ft.
NC Well Contractor Certification Number 15;,OUTER CASING" dr ells)
FROM To LOU
Russell Well Drilling, Inc. 121=_= I MATERIAL
0 ft 163 ft- 16.25 JSDR21 JPVC
Company Name
16.INNER CASINGOR, WG'(gbotheiriiiii-Elbs�6d4660y-,.?
2.Well Construction Perndt#: EHW22-01453 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc) ft. in.
3.Well Use(check well use): _f+'t ft. In.
17.SCREEN:,
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. fL in.
DGeothermal(Heating/Cooling Supply) IiiResidential Water Supply(single) it. ft. in.
Ohidustrial/Commercial OResidential Water Supply(shared) 18.GROUT ..........-
Olrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fL Grout Poured
OMonitoring ORecovery ft. ft.
Injection Well: ft. rL
[]Aquifer Recharge DGroundwater Rentediation
19.SANDIGRAVELrPACK.(if.*Oijlieiible)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EM ACEMENTMETHOD
OAquifer Test OStormwater Drainage fL M
OExperimental Technology 0 Subsidence Control
DGeothernial(Closed Loop) OTracer 20,13RILLING LOG:(iitta
oGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIMON(color,hardness,soil/rock type,grain size,etc.)
0 58 rt- Dirt
4.Date Well(s)Completed: 8-8-22 Well ID# 58 It- 145 ft- Rock
5a.Well Location: ft. ft. ,2 i:z
Martin James
Facility/Owner Name Facility ID#(if applicable) M ft SEP o 2022
2721 Cherry Lane, Sifford Rd, Denver, NC 28037 ft it.
Physical Address,City,and Zip fL ft. Un4
Lincoln 21.REMARKS
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.Certification:
35' 42.500' -N080' 98.072' W elaz:" 8/15/2022
6.Is(are)the well(s): 011'ermanent or OTemporary 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: ElYes or MNo 15A NCAC 02C.0100 or 15A NC4C 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-Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: i
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 145 ft
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 50 24a. For All Wells: Original f6nn to Division of Water Resources (DWR),
(fL) Information Processing Unit,1617 jMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC�17699-1636
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWI?,CCPCUA
13a.Yield(gpm)40 Method of test:Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTH Amount: 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018
i