GW1-2021-00506_Well Construction - GW1_20210210

4
r =Pant Form -
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION k
3245 A 150 f- 815 ft j
ft. ft. j
NC Weil Contractor Certification Numbcr 15 OUTER CASING for multi cased wells OR LINER if a' livable
Russell Well Drilling, Inc. FROM TO DIADTETER THICKNE S MATERIAL
Company Name
0 ft• 31 ft- 1 6.25 In SDR21 I PVC
OSOOW 46.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State, Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.-SCREEN
FROM TO DIAMETEW SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. inl
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in*
Industrial/Commercial DResidential Water Supply(shared)
Is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
Monitoring Recovery
injection Well: ft ft
Aquifer Recharge [)Groundwater Remcdiation 19.SAND/GRAVEL PACK'if applicablC
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E]StormwaterDrainage fr• fr•
Experimental Technology Oj Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRII LING LOG:attach additioaalsheets if necessary)
Geothermal eatin Cooling Return Other(explain under#21 Remarks FROMI TO DESCRIPTION color,hardness solVrock type grain sizc etc.
0 R- 26 ft- Dirt
4.Date Well(s)Completed: 12-21-202C Well ID# 26 ft 845 fr. Rock
5a.Well Location:
Pert' Lowe Orchard Perry Lowe III ft. ft.
Facility/Owner Name Facility ID#(if applicable)
4085 Moore Mtn. Moravian Falls, NC 28654
Physical Address,City,and Zip
Wilkes 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36' 02.256' N 081' 12.306' W
,?OG
6.Is(are)the well(s)oPermanent or 13Temporary
Signature of Certified Well Contra Date
By signing this form I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or RJ No i;A,,,I5A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
!f thiv is a repair,fill out known well convnvction information and explain the eat r r $tl gepv of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
,9 Y'" 23.Site diagram or additional well details:
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 s� Tl
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER pf?w,6isr consttryctior details. You may also attach additional pages if necessary.
dulled: ` °SUBMITTAL INSTRUCTIONS
9.Total well depth below land"surface: 815 q(f F 24a. For All Wells: Submit this form within 30 days of,completion of well
For multiple welly list all depths ifdiiftrent(example-3@200'and 2 a(f In07" t. construction to the following:
10.Static water level below top of casing: 150 (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: I 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 Ci nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water SuoDly&Infection 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: 2 1/3 CUD completion of well construction to the county health department of the county
where constructed. k
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016