GW1-2022-01234_Well Construction - GW1_20220103

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 100 ft- 390 ft-
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for mu"i sed wells OR LINER if a !!cable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 115 It- 6.25 SDR1 JPvc
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 772 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.
7.SCREEN
Water Supply Well: 1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
r19.SAND/GRAVEL PACK !f applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type rain size,etc.
0 ft. 110 ff Dirt ?
4.Date Well(s)Completed: 11-1-2021 Well ID# 110 ft. 390 ft- ROCk
5a.Well Location: ft. ft AN 0
John Sprinkle
Facility/Owner Name Facility 1D#(ifapplicable) ft.
5465 Whispering Hills Trail, Lenoir, NC 28645 ft. ft. t�0
Physical Address,City,and Zip fL ft.
Caldwell .21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35' 50.832' N 081 .39.903' wNZ,6z) 12/31/2021
6.Is(are)the well(s): I11'ermanent or ❑Temporary Sigma urc o�f Cemfied 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 ONo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis 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: 390 (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 2@100�
10.Static water level below top of casing: 100 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.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: 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:L1 Air Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1611
T
13b.Disinfection type: U I H Amount: 1 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018