GW1-2021-00031_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 60 ft. 285 ft•
ft. fL
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• 60 ft 6.25 in SDR21 PVC
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 320035 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) TResidential Water Supply(single) g g, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
OIrrigation ❑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:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ro 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) ft' 5
) ❑Other(explain under#21 Remarks) FROM 5 DESCRIPTION rotor,harda sowroek to size,,etc.
5 ft. Dirt
4.Date Well(s)Completed: 10-20-2021 well ID# 55 fa 285 tt•
5a.Well Location: ft. fL
Willow Homes, LLC Jason Wood ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. n y
254 Treebark Rd, Statesville, NC 28625 fL f. NOV
Physical Address,City,and Zip ft. ft.
I red el l 21.REMARKS
County Parcel Identification No.(PIN)
rP-TORMAnlM PRTcF3s n ,..,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatnong is sufficient) 22.Certification:
35' 53.025' N 081' 57.473' W
10/20/2021
,A,. -) 2em�
6.Is(are)the well(s): WPermanent or ❑Temporary Si0iattk_cofCcrtifi&J Well Contractor Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!lNo 1 SA NCAC 02C.0100 or 1 SA 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 hack 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: 285 (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 1@100')
10. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f
II.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
20 Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) L1 Method of test:Air
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