GW1-2022-10713_Well Construction - GW1_20221205

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 ft 900 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if-a Ilcable-
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
'Company Name 0 % 38 ft 6.25 in SDR21 JPVC
1 A I7 16.INNER CASING OR TUBING.(eothermal closed-loon) _
2.Well Construction Permit#: V V 5 f ,FROM TO DIAMETER I T2HCIQv-ESS I MATERIAL
List all applicable well construction permits C.e.UIC,Coumty,•State.Variance,eta) ft. ft in.
3.Well Use(check well use): ft. ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) fflResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000GPD FROM TO MATERIAL EWLACEMENTMETHOn&AMOINT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
OAquifer Recharge ❑Groundwater Remediation ft. ft
CK
❑Aquifer Storage and Recovery Cl 19.SAND/GRAVEL PA if a` licable
Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets'if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To I DESCRIPTION(color,hardness,solllrocktypc grain size,eta)
0 ft• 33 ft-
Dirt
4.Date Well(s)Completed: "14-22 Well ID# 33 ft. 900 ft. Rock
5a.Well Location: ft. ft Yam,a-y j V _•
Zachary&Casey Johnson Lee Boggs M ft -ft , ,
Facility/Owner Facility ty ID#(ifapplicable)800 McCurdy Rd, Taylorsville, NC 28681 ft. ft. ML
in; ir: i�� �fF ►
Physical Address,City,and Zip -
Alexander -21.REMARKS,-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one lat/long is sufficient) 22.CertitieatioD:
35'99.206' N-091 04.384' W 11/14/2022
6.Is(are)the well(s): V]Permanent or ❑Temporary Signature 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 MNo 15A NCAC 01C.0100 or ISA NCAC 01C.0200 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 1111 remarks section or on the backofthisfonn.
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-leis needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth belowiland surface: 900 (ft,)
For multiple wells list all depths if different(example-3@200 and 1@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 100 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6.25 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(gpm) Method of test:
Air Perron Program,1011 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:2 2/3 cup i
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018