GW1-2021-00011_Well Construction - GW1_20211208

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 So it- 265 ft•
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 92 ft 6.25 1n SDR21 JPvc
Company Name
R
16.INNERCASING OR TUBING(geothermal closed400
2.Well Construction Permit#: 836 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc) ft. % in.
3.Well Use(check well use): fL It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) lilikesidential Water Supply(single) ft, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 f• Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL:PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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,soivrock in sire,etc
0 ft. 87 ft. Dirt
4.Date Well(s)Completed: 10-27-2021 Well ID# 87 ft. 265 ft. Rock
5a.Well Location: fL M
Ron Morales fL fL
Facility/Owner Name Facility ID#(if applicable) fL ft.
5848 Box Turtle Run, Lenoir, NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft.
Caldwell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
35' 50.584' N 081' 41.720' w 11/4/2021
i' �1'�a�lD
6.Is(are)the well(s): *Permanent or ❑Temporary
eignature fied Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If thin 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:
You may use the back of this page to provide i'c do info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same �•� tf'e
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also a additiona pagek i 4aty.
drilled: 24.SUBMITTAL INSTRUCTIONS DEC 4 8 7021
9.Total well depth below land surface: 265 (ft.) Submit this GW-1 within 30 days of well completion Rer the following:
For multiple wells list all depths if different(example-3@200'and 2@I00') U.F"'R��.�TO;'i
10.Static water level below top of casing: 80 00 24a. For All Wells: Original form to D g��Vly Ultlf1
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Ra eigh, 7b99-161'7
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r 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) 15 Method of test: I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 2/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018