GW1--02824_Well Construction - GW1_20240506

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 60 ft. 425 ft- I I
ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wells)OR LINER(if a" licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 54 ft. 6.25 i in. SDR21 PVC
R
"16.INNER CASING'OR TUBING"(geothermal closed-loop).:
2.Well Construction Permit#: 809 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 • • I,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. .
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
0 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
19.SAND/GRAVEL PACK(if applicable)
❑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.
❑Geothermal(Closed Loop) ❑Tracer •-20:DRILLING LOG(attach additional sheets if necessary) -- .
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)0
0 ft. 49 ft Dirt
4.Date Well(s)Completed: 04-05-2024 Well ID# 49 It. 425 ft Rock
5a.Well Location: ft. ft. I, is ` . , i ;• �
Larry.Fuiwiler Brushy Mtn. Builders ft. ft. _'ft. ft. 7t.
Facility/Owner Name Facility ID#(if applicable)
Roby Martin Rd, Lenoir NC 28645 ft. ft. ;^;Z t '7 UR
ft. ft . a C.ntrui�t��v
Physical Address,City,and Zip I tr::,:
Caldwell 2L 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: i
35.954.92' N 81.621 .47' W 1.4,A-.-) Wa.6„4„,L,L, 4/26/2024
6.Is(are)the well(s): OPermanent or ❑Temporary cure of Certified Well Contractor I 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: DYes or L'JNo 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#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:425 (ft) Submit this GW-1 within 30 dayi 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 forni 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"+"
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 Openl-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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 12 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/2 cups
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i ' Revised 6-6-2018