GW1-2021-01549_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell RECEIVED 1a.WATER zoivgs
FROM TO DESCRIPTION
Well Contractor Name 3254 A MA L MAR
X 9 rl Goej 1 40ft• 165 ft'
ft. ft.
NC Well Contractor Certification Number Inforri.ation Processing Unit 15.OUTER'CASING for multi-cased;wells"OR LiNER. lieable
Russell Well Drilling, Inc. DWR Section FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 72 ft. 6.25 in SDR21 PVC
Company Name
AP-306014 46.DINER CASINGOQWTUBING "eothernial closed-loo .-
2.Well Construction Permit#: FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits li.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN ,.;.
Water Supply Well: FROM I TO DIAMETER s SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. is
Industrial/Commercial ®IResidential Water Supply(shared)
18.:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
Monitoring ORecovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Rcmcdiation
19.SAND/CRAVEL:P,AGK�if 8 licatilC€=- - - ' " "
Aquifer Storage and Recovery [' Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRIi.LING LOG'attacfi additioual'slieefs if,necessar
Geothermal eatin C oling Return Other(explain under#21 Remaksj FROM TO DESCRIPTION color,hardness sell/rock type,grain size,etc.
0 ft• 67 ft Dirt
4.Date Well(s)Completed:01-28-2021 sell ID# 67 ft• 165 ft Rock
5a.Well Location: ft. ft.
Jodi Ballard Sedgewick Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
261 Noel Road, Harmony, NC 28634 ft. ft.
Physical Address,City,and Zip ft. ft.
Iredell 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) 2251�.
fieation
35' 54.244' N 080' 47.681' w
2-5-2021
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified ell Contractor Date
By signing this form.I herebv cerlify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or JM No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well comet-action information and explain the nature ofthe 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 I 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: 165 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(a 100') Construction t0 the following:
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.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
13a.Yield(gpm) 40 Method of test-Air 24c.For Water Supply&Iniection 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: 1/3 cup completion of well construction to the county health department of the county
where constructed.
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016