GW1-2022-10285_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: E
Chris C Russell 14..WATERZONES
FROM• TO DESCRIPTION
Well Contractor Name
3254 A 100 ft- 425 ft. .
ft ft. j
NC Well Contractor Certification Number 15i OUTER'CASWG fdi::multi-cased�wells:ORI INEIF if:a licable
Russell Well Drilling Inc. FROM TO DIAMETER T
' HICKNESS MATERIAL
0 ft 36 It 6.25 � In SDR21 PVC
Company Name 16.',INNER:CASINGOR;T,[1BING' 'eutliermelclosed-loo :.
2.Well Construction Permit#:W512 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) ft ft �n•
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Pubhc tt It. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) S:-GROUT "
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&f AMOUNT
Non-Water Supply Well: 0 fL 20 fr. Grout Poured
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
,i19t.SAND/GRAVEL�l'ACK-it;l,"-liceble `>i
❑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 20:DRILLINGLOG attach additiouiil.sheets'ifnecesse
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soft/rock in sin,etc
0 tt 31 �• Dirt
4.Date Well(s)Completed: 10-18-2022 Well ID# 31 ft 425 R• RoCk
ft ft
5a.Well Location:
Joshua Orr J. Scronce ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
170 Deerview Dr., Taylorsville, NC 28681 ft ft. .
Uez
Physical Address,City,and Zip ft. ft `x
Alexander 21.'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
35' 80.008' N 081' 15.352' W 7 10/18/2022
6.Is(are)the well(s): GiPermanent or ❑Temporary ftiatilre ofCertified Well Contactor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the native of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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:425 For multiple wells list all depths (ft) Submit this GW-1 within 30 days of well completion per the following:
if different(example-3@200'and 2@100�
10.Static water level below to of casing: 100 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
p g: 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)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 100,000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)4 Method of test:Air i
13b.Disinfection type: HTH Amount: 1 CUp ? y
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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