GW1--03800_Well Construction - GW1_20230602

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 40 ft. 485 ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 100 ft 6.25 in SDR21 1PVc
W540 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It.
ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT AIETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑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 color,hardness,soil/rock type,grain size,etc.)
0 ft. 95 ft. Dirt
�--
4.Date Well 4-21-23 s)Completed: Well ID# 95 ft- 485 ft- Rock
5a.Well Location: ft
James Fortner fL ft. , (: `� 2�CF
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. lf�r
Russell Gap Rd, Taylorsville NC 28681 ft ft. , • j -1 �{ ;;.; a
Physical Address,City,and Zip ft. ft.
Alexander 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22. ertification:
35' 91 .798' N 81'23.443' W - 5/1/2023
6.Is(are)the well(s): UlPermanent or ❑Temporary Signature ofCcrtified Well ntractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LhNo 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: 485 (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'am12@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijf Static water level below top of casing. (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground hnection 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 Wm) 20 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/2 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018