GW1--06456_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
I I
_
Chris C Russell 14.WATER ZONES'
FROM TO
Well Contractor Name 40 ft. 325 ft. DESCRIPTION
3254 A -
ft. ft. I '
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 76 ft. 6.25 I ' 1n. SDR21 PVC
Company Name -- -
W598 16.INNER CASING OR TUBING'(geother'mal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc). ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER, SLOT SIZE _TH ICKNESS I MATERIAL
®rAgricultural OMunicipal/Public ft. ft. in.
%Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.'
IN i Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation ' _FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Grout : Poured
*I Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
NIAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
MI Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
"IAquifer Test EtStormwater Drainage ft. ft. i,
®Experimental Technology E3Subsidence Control ft. ft.
%I Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
®I Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
0 ft. 71 ft. Dirt
4.Date Well(s)Completed:9-12-2024 Well ID# 71 ft• 325 ft Rock
5a.Well Location: ft. ft.
Bel Yea LLC James Mitchell ft. ft. e-
Facility/Owner Name Facility IN(if applicable) ft. ft. ' I '4.3....,(+,,,,+is-1 V^ ^tl
6199 All Healing Springs Rd, Taylorsivlle NC 28681 ft. ft. {. NOV i', t: 2024
ft. ft.
Physical Address,City,and Zip
Alexander 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Ce 'f ation:
35.999.42' N 81.270.11' W
10-14-2024
6.Is(are)the well(s)JPermanent or )Temporary Sign f Certified ell Contractor Date
By signing this form,I hereby certibr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or3No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@I00') construction to the following: I
•
10.Static water level below top of casing:40 __(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
•11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this.form within 30 days of completion of well
12.Well construction method: construction to the following: I '
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
10 13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Iniect'ion Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 Q1p completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2-22-2016