GW1-2021-06816_Well Construction - GW1_20210309

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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
3254 A 60 f1• 525
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-easel►wells OR LINER if a "livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 75 ft- 6.25 '" SDR21 PVC
16.INNER CASING OR TUBING 'eothermal closed-loop)_
2.Well Construction Permit#/:0418 W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State, Variance,etc.) tt. H. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: FR M TO DIAMETER SLOT SIZE TIirCKNE55 MATERIAL
Agricultural �Municipa]/Public ft ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial E311esidential Water Supply(shared) ls.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
Monitoring DRecovery ft. fL
Injection Well:
tt. ft.
.Aquifer Recharge 13Groundwatcr Rcmcdiation
19.SAND/GRAVEL PACK ifa livable
bm
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING'LOG attach additional sheets if necessary)
Geothermal eating/Coolie Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness solViock rain size eta
0 ft• 70 ft. Dirt
4.Date Well(s)Completed:2-10-2021 well ID# 70 tt. 525 f1• Rock
ft. ft.
5a.Well Location:
Pete Lucarelli f`' ft'
Facility/Owner Name Facility ID#(if applicable)
1660 Walshtown Rd, Boomer, NC 28606
Physical Address,City,and zip ft. ft. ocessing Unit
Wilkes 2L REMARKS PAR Sertibn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latdong is sufficient) 22.Certification:
36' 05.403' N 081' 14.970' W i /9 202
6.Is(are)the well(s)oPermanent or Temporary Si of Certified well Contractor Dace
By signing this form.1 hereby certify ihai the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJYes or MNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair•fill out known well constuction information d 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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 525 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a�200'and 2L1001 construction to the following:
10.Static water level below top of casing:60 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in.) 24b.For Inlection 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) 12 Method of test: Air 24c.For Water Supply&Inlection 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 2/3 CUP completion of well construction jto;the county health de ent of the county
where constructed.
h
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Res Revised Revised 2-22-2016