GW1--05196_Well Construction - GW1_20240903

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 ft 345 ft•
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 130 It. 6.25 SDR21 PVC
Company Name
201642 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. m'
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO 'IA IERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if ap tp able)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc.)
0 R 125 f• Dirt
4.Date Well(s)Completed: 8-7-2024 Well ID# 125 ft. 345 e. Rock .-- - _ -- _• , -
5a.Well Location: ft. ft. • ,--`-,•,.... .
•
Seth VanArdsdale ft. ft. Ep ' ; 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
204 Rosentom Dr. Stony Point NC 28678 rt. ft.
Physical Address,City,and Zip ft. ft.
I red el I 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. rtiflcation:
35.784.77' N 81 .086.72' w .........e_ 8/12/2024
of6.Is(are)the well(s): Permanent or ❑Temporary
atfied Well ntiacto 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 I!lNO ISA 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 GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I 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: 345 (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,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+•'
11.Borehole diameter: 6.25 (ID.) 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
13a.Yield(gpm)4 Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 C u p
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018