GW1--06359_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES• I
FROM TO DESCRIPTION
Well Contractor Name
3254 A 40 ft. 325 ft.
ft. ft f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
0 ft. 53 ft. 6.25 111"• SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 962
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.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/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
OMonitoring ❑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 ft.' ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft. 53 ft. Dirt
4.Date Well(s)Completed: 6-6-23 Well ID# 53 ft 325 ft Rock
5a.Well Location: ft. ft. ' a �' It Y�,,,,, 3
Daniel & Pamela Perez Chad Helton ft. ft. s o:�.:Lt....-`' --.
Facility/Owner Name Facility ID#(if applicable) ft. , ft S E P 9 1 Z023
1488 High Valley Way Lenoir NC 28645 ft. ft. ^.-%7)r_,_ --,,, tic
Physical Address,City,and Zip ft. ft. DA vy J N ,.v`y
•
Caldwell 21.REMARKS ' •
•
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertification:
35' 89.432' N 81'.65.555' W 8/17/2023
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certifie42-tz-e
d We 1 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 I5A 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: 325 (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') I '
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 at') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
6.25 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ari 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) 20 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018