GW1-2022-01153_Well Construction - GW1_20220103

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
3254A 60 ft• 245 ft•
ft ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER if a Ocable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
p ft. 81 ft. 6.25 1n SDR21 JPVC
Company Name
AP303309 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1IResidential Water Supply(single) ft. ft. in.
❑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 e• Grout Poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El 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,soil/rock type rain size,etc.)
0 ft. 76 ft. Dirt
4.Date Well(s)Completed: 11-29-2021 Well ID# 76 ` 245 ft. Rock
5a.Well Location: ft. ft.
. r
Ricky Driver Driver Custom Homes ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. -
3059 Sandy Springs Rd, Harmony, NC 28639 ft. ft. CTIt
Physical Address,City,
ys ty,and Zip ft. ft. � •r�n�! '0�`�1�'^ )
I redel i 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22. r'tifieation•
36'02.884' N 080' 43.104' W
12/31/2021
6.Is(are)the well(s): 41Permanent or ❑Temporary Signature of Certified Well"Contractor 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 [!]No 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft-) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources ('DWR),
If Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 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)
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) 50 Method of test: Air
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