GW1--02826_Well Construction - GW1_20240506

ii
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Chris C Russell .14.WATER ZONES ..
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft. 365 ft. 1 1
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
Russell Well Drilling, Inc. • FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 57 ft. 6.25 i' in' SDR21 PVC
1019 :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) l!Residential Water Supply(single) g, ft. in:: •
❑lndustrial/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.
DAquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
I.
❑Experimental Technology 0 Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional'sheets.if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 ft. 52 ft. Dirt
4.Date Well(s)Completed:4-2-2024 Well ID# 52 it 365 ft Rock
5a.Well Location: ft. ft h ^ a--^ti t
Daniel&Patricia O'Shanressy John Sprinkle ft. ft' I 1:._t.. L.i 4? 1.-.I /
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY A 17/� 2024
1508 High Valley Lenoir NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft. lrs ) t+Sin;„^kl
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:
35.341.34' N 81.65.834' W ; 473 � 4/2/2024
6.Is(are)the well(s): i'IPermanent or OTemporary
Signature f Certified Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I'INo 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 welidetails:
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: 365 (ft.) Submit this GW-1 within 30 days If 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 0'4 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.)
Air Drilled Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
!. I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 cup I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
1 .