GW1--03413_Well Construction - GW1_20240610

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
200 ft• 805 ft.
3254 A
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 THICKNESS MATERIAL
0 ft. 67 ft. 6.25 in• SDR21 PVC
Company Name
1147 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) OResidential 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 f• 20 ft- Grout Poured
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑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.
❑Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock tope,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 63 ft. Dirt
4.Date Well(s)Completed: 4-8-2024 Well ID# B3 ft. 805 ft• Rock
5a.Well Location: ft. ft. �_ T_ ,, i[, `a
Smith Jennifer&Poloff Dennis ft. ft. k i U i-•1 v 6'
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 l J N 1 0 aZ4
1073 Round Rock Rd, Lenoir, NC 28645 ft. ft. J
ft. ft. -i{ I p•4C
Physical Address,City,and Zip aiSOG
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.C r'tiflcation:
35.899.38' N 81.651.94' - 5-10-2024
6.Is(are)the well(s): OPermanent or ['TemporarySignature of Certified 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 ONo 1 SA NCAC 02C.0100 or 1 5A 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 GeoprobelDPT 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 (addOver'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 805 (B') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiil different(example-3(a,200'and 2Qa 100')
200 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (IL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+•'
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
2 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTC Amount: 2 cups
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018