GW1-2021-07528_Well Construction - GW1_20210903

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 200 ft- 365 ft.
ft. fL
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 31 ft.
6.25 in. SDR21 PVC
Company Name
p p '16.INNER CASING OR TUBWG(geothermal closed-too
2.Well Construction Permit#: 788 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• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft• h• in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ln7 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
f[. ft.
❑Aquifer Recharge ❑Groundwater Remediation
79.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color,hardness,sosoil/rockrain size,etc.
) ❑Other(explain under#21 Remarks) 0 ft' 26 ft- Dirt
4.Date Well(s)Completed: 5-6-21 Well ID# 26 ft' 365 ft• ROCk
5a.Well Location: ft. fL
James Davis B. Davis fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5024 Blowing Pines Ct., Lenior, NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft. Q 2
Caldwell 21.REMARKS �7ORW
County Parcel Identification No.(PIN) P�O�S
n ' pN1R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35' 53.309 N 081' 39.768' w
' � 8/11/2021
6.Is(are)the well(s): OPermanent or ❑Temporary ture o Certified WA Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: 200 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ifwater level above casing,use'+
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: i r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
L1
13b.Disinfection type: L1 L_ITL_I Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018