GW1--02072_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: P ,
1.Well Contractor Information:
Chris C Russell 1a:;WATERZONEs
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft, 285 ft
ft. ft. 1
NC Well Contractor Certification Number ',15:OUTER CASING(for multiased wells)OR LINER,(if ap licable) -
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 40 ft- 6.25 j, :in. SDR21 PVC
Company Name
-.16.INNER CASING OR'TUBING(geothermaIclosed-loop)-'
2.Well Construction Permit#: 14200 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.
0 Geothermal(Heating/Cooling Supply) l Residential 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 ❑Groundwater Remediation
',I9:SAND/GRAVEL PACK(if applicable)..
µ
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft. ,
0 Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG"(attach additional'sheets if necessary) '
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type grain size,eta)
0 ft' 35 ft• Dirt
4.Date Well(s)Completed: 3-15-2024 Well ID# 35 ft. 285 ft• Rock , ,
5a.Well Location: ft. I�. °i— r ;'1 `(^^e.,t'
Paula Jones ft. ft.
APR 3 5 2021
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1048 Jones Hill Drive, Stanley NC 28164 ft. ft. In "`-a``zn }'-:::x4.,'-L
L
Physical Address,City,and Zip
ft. ft. :i.,"
Gaston ;2t.REMARKS-.i"'
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.Cer'Mallon:
36.363.29' N 81 .004.32' W ) , 2 _ 3/29/2024
6.IS(are)the well(s): C9Permanent or ❑Temporary
Sign e of Well ontractor 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 nNo 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: 285 (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: 60 (ft') Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) Program,1636 MSC,Raleigh,NC;27699-1636
12.Well construction method:Air Drilled 24c.For Water Supply and Opei-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) 50 Method of test:
Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTC Amount: 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2018