GW1--07966_Well Construction - GW1_20231208

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 60 ft. 185 fa
ft. ft. 1 ,
NC Well Contractor Certification Number Inc. 15.OUTER CASING(for multi-cased_wells)OR LINER(if ap licable)
Russell Well Drilling, FROM TO DIAMETER THICKNESS MATERIAL
9 0 ft. 71 ft• 6.25 in* SDR21 PVC
Company Name
W554 ' 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) I lResidential 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 19fSAND/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)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type t slze etc.)0
0 ft, 66 rt. Dirt
4.Date Well(s)Completed: 11-10-2023 Well JD# 66 ft• 185 ft• Rock.
•
5a.Well Location: ft' ft.
Allen Shook SW Associates ft. ft.
' 'a ' y
Facility/Owner Name Facility ID#(if applicable) ft. ft. i y is ® , $�u'
_ ,
4227 All Healing Springs Rd, Taylorsville NC 28681 ft. ft.
Physical Address,City,and Zip ft. ft. D C 0 8 2023
Alexander 4_ .
In,org,0Jon 1 sut.,,.�.•.v.n..,.
County Parcel Identification No.(PIN) Ct l('y�''�!i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C • cation: -'
35.978.80' N 81.280.10' W21-4,2 11/22/2023
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well tractor; 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 I SA NCAC 02C.0100 or ISA 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: 185 (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@l00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 014 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.)
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
Permit Program,1611 MSC,Raleigh,
Yield(gpm) 30 Method of test:Air NC 27699-1611
13b.Disinfection type: HTC Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018