GW1--07828_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES° - L.
FROM TO DESCRIPTION
Well Contractor Name
60 it, 165 rr
3254 A 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
0 ft. 82 ft• 6.25 ' i"• SDR21 PVC
Company Name 9^^ W 16.INNER CASING OR TUBING(geothermal'closed-loop) _ -
0
2.Well Construction Permit#: 3`� 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 OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) PJResidential 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 it. Grout. Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 0 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.
DExperimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)_ ; ,
FROM TO DESCRIPTION(color,hardness,sotttrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft• 77 it Dlrt
4.Date Well(s)Completed: 9-26-2023 Well ID# 77 ft. 165 it Rock
5a.Well Location: ft. ft.
Thomas Minton ft.
rL '*`:.T:• :-.
Facility/Owner Name Facility ID#(if applicable) ft. ft _r �1,
269 Gene Horton Rd, Ferguson, NC 28624 ft. ft. DF C 0 8 Zr2 3
Physical Address,City,and Zip ft. ft. In et,a l i"n .7-1"_
•
Wilkes 21.REMARKS - C° _-' "::2 i_'r i
:,JC
County Parcel Identification No.(PIN) '
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.075.87' N 81 .357.07' w 4,6„....„ 11/20/2023
6.Is(are)the well(s): elPermanent or ❑Temporary Signature of Certified&ctor Date
By signing this form,I hereby certify drat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or lNo 15A 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 ivell 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: 165 (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')
24a. For All Wells: Original farm to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 Ut•) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+" I '
11.Borehole diameter: 6.25 on.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 21699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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: HTH __ Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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