GW1-2022-01238_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
3254A 100 ft. 485
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi sed'wells OR LINER if.a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
p ft. 80 ft. 6.25 1O SDR21 JPVC
Company Name
16.INNER CASING OR TUBING eolhermal closed-loo
2.Well Construction Permit#: 800 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. I in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
011Ti atlon ❑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.-SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2] Remarks) FROM
ft' 75 fL Dirt
4.Date Well(s)Completed: 1 1-2-2021 Well 1D# 75 ft- 485 ' Rock
5a.Well Location: ft. ft.
Joseph Camial Chad Helton fL ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6021 Low Country Rd, Lenoir, NC 28654 ft. ft.
Physical Address,City,and Zip ft. ft. J/1
Caldwell 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
rr' AT ICNI FIT;?!°-^S,44G INI.
(if well field,one lat/long is sufficient) 22.Cer flea'on:
35' 53-240' N 081'39.721' W 12/2/2021
6.Is(are)the well(s): WPermanent or ❑Temporary Signature of Certified Well Con&fctor 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 19No 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:
S.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: 485 (fLl Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifili ferent(example-3@200'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 (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) 5 Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018