GW1-2021-08140_Well Construction - GW1_20211109

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 fL 305 ft•
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased wells OR LINER`if a licable
Russell Well Drilling, Inc. FROM To DIAMETER TRICKINESS MATERIAL
0 ft- 65 ft- 6.25 1n SDR21 JPvc
Company Name
16.INNER CASING OR TUBING eothermsl closed-loop)
2.Well Construction Permit#: n/a FROM TO DIAMETER TRICKINESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc) ft. ft. in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
C Ag,icultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f,• g• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑In7 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
tL fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL-PACK itapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,wittrock qM gmin size,etc.
0 fL 60 ft- Dirt
4.Date Well(s)Completed: 8-26-2021 Well ID# 60 ft. 305 ft- Rock
5a.Well Location: fL ft.
Joseph Pugh fL fL
Facility/Owner Name Facility ID#(if applicable) fL ft
NOV
4082 Grace Chapel, Granite Falls NC 28630 ft. ft.
Physical Address,City,and Zip ft. ft. DVHK SECTION
Caldwell 21.REMARKS iFYORMATIMP
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 tication:
35' 50.081 N 081' 23.238' W J )eee'14�_ 10/12/2021
6.Is(are)the well(s): 14Permanent or ❑Temporary Sioisture of Certified Well CNntractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 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 I GW-I 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: 305 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ift ifferent(example-3@200'and 2@100')
10.Static water level below top of casing: 60 (R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
110.St level a above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: Air 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 27699-16 1 1
13a.Yield(gpm) 100 Method of test:Air
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018