GW1-2021-00027_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 35 ft- 405 it.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a livable
Russell Well Drilling, Inc. FROM TO DIAMETER THHCKNESS MATERIAL
0 ft 188 fL 6.25 SDR21 JPVC
Company Name
313621 16.INNER CASING OR TUBING eAtheFinal closed-loop)
2.Well Construction Permit#: FROM I 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): fL fL in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL iL in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. h ,n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 iL Grout Poured
❑Monitoring ❑Recovery fL fL
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK iPa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it. rL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIMON color,hardness,soilfrock e, in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 h• 83 iL Dirt
4.Date Well(s)Completed: 10-19-2021 Well 1D# 83 fL 405 ft. Rock
5a.Well Location: fL It.
Clayton Homes Conover iL iL
Facility/Owner Name Facility ID#(if applicable) fL ft.
143 Patchwork Dr, Statesville, NC 28677 fL ft. 1
Physical Address,City,and Zip fL ft
redel l 21.REMARKS rr
PROCESsm lI
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.Ce (cation:
35' 46.782' N 081' 05.536' W - 10/22/2021
6.Is(are)the well(s): @Permanent or ❑Temporary SigWur6-ofCcrfified-WeIPC&ntractor 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 ONo 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: 405 (fL) 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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 5 (ft') Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 6 1 7
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
13a.Yield(gpm) Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018