GW1-2022-09313_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD GW-1 For Internal Use only
1.Well Contractor Information: j
Chris C Russell 14.WATERZONEs .
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft- 485 ft-
ft. ft.
NC Well Contractor Certification Number IS:SOUTER GASING f6i ulti cased:wells'OR-IsINER'if a"'lic'able"
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 82 ft 6.25 in SDR21 JPVC
Company Name
W506 16.P4NEWCASING OR.TUBING'; eotherru`al eldsea loo ` K - -
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): fL ft. in.
17:'SCREEN .s `.. .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17L ft. in.
❑Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft• g• in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 7 1."
❑hTi ation ❑W ells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f° 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation i
19:SAND/GRAVELRACK if.e'"`li6ble :r N
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach e8didonsl?sheets:ifti'ecessa
❑Geothermal(Heating/Cooling Return)
TO DESCRIFrIONcolor,hardness,soiUrock rain size,eta) ❑Other(explain under#21 Remarks) O fL 77 ft- Dirt
4.Date Well(s)Completed: 8-29-22 Well ID# 77 fL 485 ft Rock ' �+
5a.Well Location: ft. ft -
Thomas Penley Clayton Homes ft. ft. OC 1 0 v 2022
Facility/Owner Name Facility ID#(ifapplicable) % ft
5553 Black Oak Ridge Rd, Taylorsville, NC 28681 ft. ft.
Physical Address,City,and Zip ft. ft.
Alexander 21.REM ARKS
.;=; ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35' 98.737' N 081' 15.363' W &e., 9/2/2022
6.Is(are)the well(s): laPermanent 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 ONo 1 SA NCAC 02C.0100 or I SA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well,constmction 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: 485 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2Qa 100�
i
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,use
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: 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 Wm) 8 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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