GW1--01267_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.•WATER ZONES :; _._` ;
FROM TO DESCRIPTION
Well Contractor Name
3254 A 40 ft. 445 ft•
ft. ft. i
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
ft. ft. in.
0 78 6.25 SDR21 PVC
Company Name 4708-28-4170 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.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in'
0 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 tt. Grout; Poured
:Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fa ft. ,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary) - `s`
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 73 ft. Dirt
4.Date Well(s)Completed: 12-22-2023 Well ID# 73 ft. 445 ft• Rock ;
5a.Well Location: ft. ft.
Chase Sharpe ft• ft. " � �-.�
Facility/Owner Name Facility ID#(if applicable) ft. ft. I t f®L£‘\ Ct
719 Harris Bridge Rd, Stony Point NC 28678 ft. ft. FEB 2 .0 20Z4
ft. ft.
Physical Address,City,and Zip c It tit�t A (iE it i�frn
Iredeli 21.REMARKS A,.^
• :,Unl`'..•
1?i/WQ/uOG
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. ertification:
35.897.91' N 81.026.11' V,r -174.,J A.a 1/19/2024
Signature of Certified
6.Is(are)the well(s): nPermanent or ❑Temporary
Wild 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 I lNo 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.
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)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 tit) 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 Opeit-Loop Geothermal Return Wells:Copy to the
(Le.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) 15 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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