GW1--05978_Well Construction - GW1_20241009

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 180 ft• 645 ft.
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. 65 ft. 6.25 i in. SDR21 IPVC
Company Name
1216 :46.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. 1 in.
3.Well Use(check well use): ft. ft. in.
-17.SCWater Supply Well: FROMBEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) ft ft. ' in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) >.18:
❑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 0 Groundwater Remediation
;'49.-SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) - ., .-
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0
it 60 it Dirt ;
4.Date Well(s)Completed: 8-14-2024 Well ID# 60 ft, 645 ft. Rock
5a.Well Location: ft. ft.
Stephen Rodemond John Sprinkle ft. ft. a ,.,w i , L. y `
s
Facility/Owner Name Facility ID#(if applicable) ft. ft. O C T 0 9 �024
4897 Soaring Top Ln, Lenoir NC 28645 ft. ft. -
ft. ft. ii,:�.r+ai.a.:,.: ;r:,r,Grtii:rd 1W.*
Physical Address,City,and Zip 1-NA.= ?t:�-^
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 titivation:
35.901.82' N 81.653.64'
W J..e 9/26/2024
6.Is(are)the well(s): I�Permanent or ElTemporary Signature of Certified well Contractor Date
By signing this form,I hereby cert j that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or I lNo 1.5.4 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 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.)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 180 (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,NO 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,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 3/4 cup ,,
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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