GW1--04948_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD(GW=1) For Internal Use Only:
1.Well Contractor Information: I I
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft• 305 ft•
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 94 ft• 6.25 in. SDR21 PVC
W 513 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.) 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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l 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 ['Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Test ❑Stormwater Drainage IL ft.
❑Experimental Technology ['Subsidence Control I ft. ft.
❑Geothermal(Closed Loop) ❑Tracer I 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUrock type grain size,etc.)
0 ft• 89 ft. Dirt
4.Date Well(s)Completed: 6-2-2023 Well ID# 89 ft• 305 ft• Rock 1...-,
5a.Well Location: ft. ft. r\'. L.:a; V'L_..U
Andrew Morrison Sedgewick Homes ft. ft. AUG Q 7"203
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
337 Landis Rd, Taylorsville NC 28681 ft. ft. la:A-7:14,2,n i'e:v ��, i
m. 4n.,
ft. ft.
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 well field,one lat/long is sufficient) 22•Certification:
35' 87.349' N 81'31 .802' W
C/7.44,;) , �� , 6/11/2023
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Wcl Contractor 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 ONo 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: 305 (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 2@100')
10.Static water level below top of casing: 80 (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
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.)
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
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 20 Method of test:
13b.Disinfection type: HTC Amount: 2/3 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018