GW1--03174_Well Construction - GW1_20230505

I
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 140 ft. 600 ft.
ft. ft.
NC Well Contractor Certification Number Inc. 15,OUTER CASING(for multi-cased wells OR LINER if a licable)
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 176 ft 6.25 in SDR21 JPVC
Company Name 1028 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1AResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 et. Grout Poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft• 171 It- Dirt p
4.Date Well(s)Completed:4-17-2023 Well ID# 171 ft, 600 ft• Rock - ,'t 2 ?
5a.Well Location: ft. ft. -..
J Guadulupe Cruze Zepede rc. rt. MAY
Facility/Owner Name Facility ID#(if applicable) ft. ft RI {_Py7 l�n$
2910 Taylorsville Rd Granite Falls NC 28630 ft. ft. - GA'AYBUNG
Physical Address,City,and Zip ft. ft.
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.C ti ication:
35.834.90' N 81 .386.15' W 4/27/2023
6.Is(are)the well(s): ]Permanent or ❑Temporary Signature of Certified WeITLIontractor Date
By signing thisform,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [INo 15A NCAC 02C.0100 or 15A NCAC 02C.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#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: 600 (ft•) 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 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 14 A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"t"
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: AI r D rl I I ed
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) o
o Method of test:Air LI Permit Program,1611 MSC,Raleigh,NC 27699-1611
T
13b.Disinfection type: UTC Amount: 1 2/3 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018