GW1-2022-10339_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Well Drilling, Inc. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 80 ft- 485 k•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING forulti-cased welW OR LINER if a
Russell Well Drilling, Inc. FROM m
TO DIAMETER THICKNESS MATERIAL
0 ft 126 fr 6.25 in- ISDR21 JPVC
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 888 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. ft. �n•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public IL ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
OlTrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 IL Grout Poured
❑Monitoring ❑Recovery tt. IL
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC9C V a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiltruck in size,etc.)
0 ft- 101 ft- Dirt
4.Date Well(s)Completed: 9-14-22 Well ID# 101 ft• 126 ft- Rock
5a.Well Location: ft. ft.
Rod Brown ft. ft.
Facility/Owner Name Facility ID#(if applicable) % ft
Painted Ridge Trail, Lenoir, NC 28645
Physical Address,City,and Zip
ft. ft.
Caldwell 21.REMARKS -
County Parcel Identification No.(PIN) �w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 2ICrt tion:
35' 88.84' N 081' 69.562 W 11/7/2022
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer16 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.0100 Well Construction Standards and that a copy
/f 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 (fL) 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 1@100�
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (M) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air
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 roducin over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 15 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