GW1--02115_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell '14.WATER ZONES . - ,- .•
Well Contractor Name FROM TO DESCRIPTION
3254 A 150 ft. 645 ft. 1
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 I THICKNESS MATERIAL
0 ft. 95 ft. 6.25 in. SDR21 PVC
Company Name
1023 Replacement Well 16.INNER CASING OR TUBING(geothernialclosed-loop). .
2.Well Construction Permit#: 10 . 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 OMunicipal/Public ft. ft. in.,
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) iS.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
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ID Salinity Barrier FROM TO MATERIAL ,.EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
i
❑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) 0 Other(explain under#21 Remarks) 0 ft. 90 ft. Dirt !.
4.Date Well(s)Completed: 3-25-2024 Well ID# 90 ft• 645 it Rock ,
5a.Well Location: ft. ft. :r,� __ L. ,,5 `7,- ,
Levesque Family Trust Moss Marlow
ft. ft. is k,..,..4.,, i k.f g.-,l "
Facility/Owner Name Facility ID#(if applicable) ft. ft. j 2 t0 7 APR 0 5 4
2029 Hitching Post, Lenoir NC 28645 ft. ft. APR ''/
ft. ft. lt4r:.,"r,..`:.::,t? ..::,�;i✓,s; I unit
Physical Address,City,and Zip C)l a`+C,i.'t"1(
Caldwell :21.REMARKS ,'.
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.Certification:
35.971.61' N 81 .486.52' W44,4,2A,.._ 3/29/2024
l'z6.Is(are)the well(s): OPermanent or OTemporary tgoaturo of Certified Well Contractor Date
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA 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#11 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: 645 (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: 150 (ft.) 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
13a.Yield(gpm) 3 Method of test:Air
Permit Program,1611 MSC,Raleigh,NCB 27699-1611
13b.Disinfection type: HTC Amount: 1 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018