GW1-2022-01236_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
3254 A 100 ft• 325 ft•
rt. Ift.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, C FROM TO DIAMETER CHICKNESS MATERIAL
0 ft- 67 ft- 6.25 in. ISDR21 JPVC
Company Name
16.1NNER CASING OR TUBING Geothermal closed-loop)
2.Well Construction Permit#: 764 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
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft g, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑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. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVEL PACK fif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage IL It.
❑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/rock type,grain size,etc.
0 rt. 62 ft- Dirt
4.Date Well(s)Completed: 11-5-2021 Well ID# 62 ft. 325 ft- Rock
5a.Well Location: ft. ft. JAN
Ronald Young Moss Marlow ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft ING IN
1492 High Valley Way, Lenoir, NC 28645 ft. ft. IP.r
Physical Address,City,and Zip ft. It.
Caldwell `21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
35' 53.581' N 081' 19.424' W 12/21/2021
6.Is(are)the well(s): GlPermanent or ❑Temporary gnature of Certified Wel 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 15A NCAC 02C.0100 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 I 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: 325 (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@I00')
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) 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(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) Method of test: Air
10 Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: HTH Amount: 2/3 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018