GW1--06469_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES I I
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft, 445 ft. 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 90 ft. 6.25 , 'in. SDR21 PVC
2023-2953 p8 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.
17.SCREEN
Water Supply Well:
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.
❑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 it Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer 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) ❑Other(explain under#21 Remarks) 0 ft. 85 ft. Dirt '
4.Date Well(s)Completed: 8-11-2023 Well ID# 85 ft• 445 ft. Rock e
5a.Well Location: ft. ft l"^;,.q"-X i�i, 1
John McComick ft. ft. f-�.�..' ..r .�...r 7 -°',r y-wa..4cr••
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1�f1 CT 0 2 2023
379 Moose Club Statesville NC 28677 ft. ft.
Physical Address,City,and Zip ft. ft. Iflivl'l�'^"�� .•,,1• V
Iredell 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' 737.51' N 80' 88.158' W 8/29/2023
6.Is(are)the well(s): CJPermanent or ❑Temporary
Signs a of Certified WelWe1 C 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 inNo 1 SA NCAC 02C.0100 or 1SA 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:445 (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)
10.Static water level below top of casing: 60 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to.DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6'25 (in.)
Air Drilled
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 12 Method of test:Air I
13b.Disinfection type: HTC Amount: 1 1/3 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018