GW1-2022-09311_Well Construction - GW1_20221006

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 100 fL 645 ft-
ft fL 4
NC Well Contractor Certification Number
15.:OUTER'CASWG Por_multi-cased wells ORL'INER,'ds'""Itcatile
.Russell Well Drilling, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
0 fL 95 fL 6.25 ! SDR21 JPVC
Company Name
16 INNER CASING OR`-TUBING `e6thermtil'cWeil4bb `i
2.Well Construction Permit#: 929 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fL It.
in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: FROM'SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in•
❑Geothermal(Heating/Cooling Supply) [EResidential Water Supply(single) fL R. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Grout Poured
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
.--19i-SAND/GRAVEU�P,AC-K�,Cifiooliciilile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING IiOG ittich';addiHon`il-sheets ifhecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM DESCRIPTION(color,huaaess soiurock in size,etc
0 ft. 90 fL Dirt
4.Date Well 9-15-22s)Completed: Well ID# 90 ft' 645 ft- Rock '� •- -
5a.Well Location: fL fL
Gary Biddle fL fL
fL If±;��; �tt.�� f-•t�'��..;s�,;�� lJr:l
Facility/Owner Name Facility ID#(if applicable) rL r:•1:^ (+r
6281 Painted Ridge Trail, Lenoir, NC 28645 fL ft.
Physical Address,City,and Zip fL ft.
Caldwell 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' 88.863' N 081' 69.174' W - 9/30/2022
6.Is(are)the well(s): DPermanent or ❑Temporary Si tore of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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.SUBNUTTAL INSTRUCTIONS
9.Total well depth below land surface: 645 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdilferent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 100 (fL) Information Processing Unit,1617,MSC,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(IUC)
Program,1636 MSC,Raleigh,NCf27699-1636
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 DWR,CCPCUA
13a.Yield(gpm)2 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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