GW1-2021-06828_Well Construction - GW1_20210419

P intform>
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM To DESCRIPIION
Well Contractor Name
3254 A 60 165
ft• ft
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa livable
Russell Well Drilling, Inc. FROM TO DIAPIETER THICKNESS MATERIAL
Company Name
0 ft• 93 ft i"6.25 SDR21 PVC 308596 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER TMCKN-ESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in•
in.
3.Well Use(check well use): ft. ft.
17.
Water Supply Well: FROM
ROSCREE TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared) -Ts-
GROUT
)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 fr Grout Poured
Monitoring ORecovery
Injection Well: tt R
:)Aquifer Recharge [)Groundwater Rcmcdiation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fr.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessaryi
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRrPTTON color,hardness soil/rock type,grain sirs ctc
0 ft• 88 fr Dirt
4.Date Well(s)Completed:3-4-2021 well ID# 88 f` 165 f• Rock p.N
5a.Well Location: ft. ft. w' 3
Kevin Krug
Facility/Owner Name Facility m#(ifapplicable)
3280 Amity Hill Rd, Statesville, NC 28677
Physical Address,City,and Zip ft. ft.
I red el l 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.C rtifiCation.,.
35' 46.227' N 081' 02.182' W 3 .Z3-20z/
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified ell Contractor Date
By signing this form.1 herebv certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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:
A.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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (fl•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Est all depths ifdifferent(example-3L200'aml 2(a 100) construction t0 the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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) 15 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016