GW1-2021-07628_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 100 ft- 225 ft,
ft. ft.
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- 51 ft 6.25 in SDR21 JPVC
Company Name
0753 16.INNER CASING OR TUBING eothermal closed-loop) - ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc) ft. fL in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public @. ft in.
❑Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) g• ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) "18.-GROUT
-
❑1ni tion ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 fL Grout Poured
❑Monitoring ❑Recovery ft, ft
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
-19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack type,grain stm,etc.
0 ft• 46 fL Dirt
4.Date Well(s)Completed: 8-6-21 Well ID# 46 ft 225 It- Rock
5a.Well Location: ft. ft
John Davis Dream Builders ft ft
Facility/Owner Name Facility ID#(if applicable) ft. fL
Sweetwater Rd, Majescit Mtn. Boomer, NC 28606
Physical Address,City,and Zip ft. ft. $sing
Wilkes 21.REMARKS r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C fieation:
36; 04.493' N 081' 18.666' W 8/23/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Si of,
We ontractor Date
By signing this form,I hereby certify that the wetl(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A 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: 225 (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@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) 100 Method of test: i r
13b.Disinfection type: HTH Amount: 1/3 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018