GW1-2021-01632_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell I&WATERZONEs
Well Contractor Name FROM To DESCRIPTION
3254 A 40 ft- 485 ft.
ft. ft.
NC Well Contractor Certification Number 15:0UTERCA8INGf6rmulti-cased wells OR:LINER ife" livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 70 ft- 6.25 In SDR21 PVC
16 INNER CASING ORTUBING'eothermal closed4bo
2.Well Construction Permit#: W442 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(r.e.UIC,County,State, Variance,etc.) Ct. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 41 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERTAL
Agricultural DMunicipaM/ ublic ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. in
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
Monitoring DRecovery, ft. ft.
Injection Well:
rt. ft.
Aquifer Recharge [3Groundwatcr Rcmediation
19.SAND/GRAVELPACK:ifa" licablc #s
[Aquifer
ifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test 13Stormwater Drainage ft. ft.
erimental Technology Subsidence Controlhermal(Closed Loop) Tracer 20.<DRILLING LOG attach"additionalsMeets If necessathermal(Heating/CoolingRetum Other(explain under#21 Remarks FROM TO DESCRTPTION color,hardness solUrock raln size etc
0 ft• 65 ft• Dirt
4.Date Well(s)Completed: 10-8-2020 well ID# 65 ft 285 ft• Rock
5a.Well Location:
Tim Pfister ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. s +"-
1169 Bowman Ct, Taylorsville, NC 28681 ft. ft.
Physical Address,City,and Zip f` ft. 1
21•Alexander REMARKS
County Parcel Identification No.(PIN) O�5p
JF� essill nl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
pVcilon
(if well field,one lat/long is sufficient) 22.Ce ification:
35' 48.189' 081' 17.356' _
N W .3-20z1
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified well Contractor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or W No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well cownvcfion 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 485 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Avt all depths ifdifferent(example-3(a)200'and 2(a3100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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 cowry,cable, method: construction to the following:
(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 276994636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 1/3 cuD completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016