GW1-2021-00122_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) 1, For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft. 500 ft-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for molt(cased wells OR LINER a livable
Russell Well Drilling, Inc. FROM To DIAMETER TIHCKNESS MATERIAL
0 ft- 74 ft 6.25 to SDR21 PVC
Company Name .16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 0754 W 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: i 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18:GROUT
❑Irrigation ❑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:
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/rock rain size,etc.
0 ft- 69 fL Dirt
4.Date Well(s)Completed: 08-11-2021 well ID# 69 ft- 500 ft- Rock
5a.Well Location: fL ft.
David Dyer fL fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
725 Ruritan Park Rd, North Wilkesboro, NC 28659 ft. ft.
Physical Address,City,and Zip ft. ft. 1 V
Wilkesboro AL REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ITTORMATInPI PROCE . `
(if well field,one lat/long is sufficient) 22.Cc Mention.•
35' 11 .709' N 081' 10.508' W 10/5/2021
CG Z' Q
6.Is(are)the well(s): permanent or ❑Temporary Sr of Certified Well C&ntractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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: 500 (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 1@100)
10.Static water level below top of casing: 80 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level above casing,use'+
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air 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) 10 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018