GW1-2021-04615_Well Construction - GW1_20210510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATERZONES
pPROM To DESCRIPTION
Well Contractor Name 100
ft. 365 ft'
3254 A mAY 1 -1 2021
ft. ft.
NC Well Contractor Certification Number
I7 ivlll,�.,` 15.OUTER CASING for multi-cased welts OR LINER if a" licable
Russell Well Drilling, Inc. rv1;�� FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p''^"Iz 0 ft 32 ft 6.25 SDR21 I PVC
329314 16.INNER'CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UiC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
37.'SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipatTublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft,
IndustriaUCommercial Residential Water Supply(shared)
:t8:GROUT
_ litigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
:)Monitoring Monitoring _Recovery
injection Well: ft. ft.
Aquifer Recharge iDGroundwatcr Rcmcdiation
19.SAND/GRAVEL:PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
_ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLMG LOG attach additional sbeets if necessa
Geothermal eatin Coolin Return) FROM TO DESCRIPTION color,hardness soil/rock rain size etc.
g/ Other(explain under#21 Remarks) 0 ft. 27 It- Dirt
4.Date Well(S)Completed: 3-24-2021 Well ID# 27 ft 365 ft' Rock
ft.
Sa.Well Location: ft.
Michael Lippard Jason Wood ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1620 Country Hill Dr., Salisbury, NC 28147 ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 21.REMARKS
County Parcel ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22. ertifieation-
35' 40.340' N 080. 36.015' W
3-25-2021
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form.I herebv certifv that the wells)tvas(were)constructed in accordance
7.is this a repair to an existing well: n Ves or oNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fdl out known well ennanvction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3L200'and 2L100') construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
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
(i.e.auger,rotaaryry,,action 12.Well construction method: construction to the following:
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) 30 Method of test: Air 24c.For Water Supply&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: 3/4 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