GW1--05979_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Chris C Russell ;'14.WATER ZONES; !
FROM TO DESCRIPTION
Well Contractor Name 80 ft. 425 ft. 1
3254 A ft. ft. 1
NC Well Contractor Certification Number 15.`OUTER CASING(for multi-cased OR LINER(if ap licable)- `
Russell Well Drilling, Inc. FROM TO DIAMETER, THICKNESS MATERIAL
0 ft. 75 ft. 6.25 [ SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) ', .-
2.Well Construction Permit#: 1174 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 ,,:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(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 ft. 20 ft. Grout Poured
[Monitoring ['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
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ID Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG(attach additional sheets if necessary) . • •._ -,
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 70 ft. Dirt ,
4.Date Well(s)Completed: 4-12-2024 Well ID# 70 ft. 425 ft. Rock
ft. ft.
5a.Well Location:
Bobby & Donna Myers ft. ft. ll _`'`--`'.„'L.:° 'f t '
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1785 High Country Rd Ext., Lenoir NC 28645 ft. ft. OCT 0 2024
ft.
Physical Address,City,and Zip ft. l , .i.c r. '-r,;, 1;:-..1 1 j'
fi � �
Caldwell
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:
35.971.61' N 81.486.52' w C-4) ' 9/25/2024
6.Is(are)the well(s): ltPermanent or ❑Temporary
tified Well Contractor Date
By signing this form,I hereby certh'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ONo 15A NCAC 02C.0100 or I SA 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.
i
drilled: 24.SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface:425 (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: 80 (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 (►n•) Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: 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
Q Air Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 8 Method of test: I '
13b.Disinfection type: HTC Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018