GW1-2022-10337_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 100 ft- 485 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if cable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 165 f4 6.25 SDR21 JPVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#• 851 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) rmResidential Water Supply(single) R• R, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Oft-rigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 IL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
R. R.
❑Aquifer Recharge []Groundwater Remediation
19.SANDlGRAVEL PACK H applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness,soittrock type,givin size,etc.)
0 ft 160 R- Dirt
4.Date Well(s)Completed: 9-1 6-22 Well ID# 160 ft' 485 ft- ROCk
5a.Well Location: ft. ft.
Ronald Hicks rL fL `
Facility/Owner Name Facility 110(if applicable) ft. ft. NOV � A
Box Turtle Run, Lenoir, NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft. i'JL3't]/$ unk
-
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' 89.136' N 080' 69.240' W - 10/3/2022
6.Is(are)the well(s): IEPermanent or ❑Temporary Si of Certified Well Cbntrwor Date
By signing this form,I hereby certify that the wells)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.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction 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 (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1Q100�
10.Static water level below top of casing: 100 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+.• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,.i
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.For Water Supp!X and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county-environmentaleat department o e county where insta ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)8 Method of test: Air Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018