GW1--07215_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Chris C Russell "14:WATER ZONES ;-'; "
Well Contractor Name • ` FROM TO DESCRIPTION
3254 A 50 ft• 285 ft• 1 1
ft. ft. 1
NC Well Contractor Certification Number -.15.OUTER CASING(for multi•eased.wells)ORI LINER(if ap"licable) -
Russell Well Drilling, Inc. • FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 120 ft• 6.251' ' in' SDR21 PVC
Company Name 16.INNER'CASING OR TUBING t(geotherntal-closed-loop)
2.Well Construction Permit#:400507 565011 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft ft. in.
1ZSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑Municipal/Public ft. ft. in
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) f8r''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. -
OExperimental Technology 0 Subsidence Control ft. ft. 1
❑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' 115 ft• Dirt 1
4.Date Well(s)Completed: 10-26-2023 Well ID# 115 ft. 285 ft. Rock;. ' =-tj
5a.Well Location: ft ft N(,V �11Z�1
Coty Edwards ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. il i; ;,r a„? a ram.-:,a,;,,„i l t.,.z
1285 Belk Rd, Mount Ulla, NC 28125 ft. ft. D'.`.;Cd::=0(2.4
ft. ft. I
Physical Address,City,and Zip
Rowanz1:REMARxs-r.
County Parcel Identification No.(PIN)
r,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35. 647.50' N 80.741.30' W ,
di.-4/�J 1a~,4� 11/7/2023
6.Is(are)the well(s): OPermanent or ❑Temporary e of Certified ell 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 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. j
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: 285 (ft) Submit this GW-1 within 30 dais ofwell completionthe following:
For multiple wells list all depths ft-different(example-3@200'and 2@1000 yi per
10.Static water level below top of casing: 50 (fG) 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
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:Air Drilled i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmentk 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: HTH Amount: 3/4 cup
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018