GW1-2022-01778_Well Construction - GW1_20220214

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 80 ft. 440 ft•
ft ft.
NC Well Contractor Certification Number �+ 15 OUTER CASING formu1N casedtwells OR LINER if a IIcsble
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 76 ft 6.25 '° SDR21 PVC
Company Name
1.6.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 876 FROM To I 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19:SANDlGRAVEIi'PACK(if a licable
❑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 sheets4f uecessa ' ;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soitfmck type,gnin size,etc.
0 ft. 71 It. Dirt
4.Date Well(s)Completed: 01-27-2022 Well ID# 71 fQ 440 ft- Rock i
5a.Well Location: ft. ft
Vickie Smith `t `t
Facility/Owner Name Facility lD#(if applicable) ft ft fl ftgonft Lim
1226 Honeycutt Lane, Lenoir, NC 28645 `t ".
Physical Address,City,and Zip ft. ft.
Caldwell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35'92.734' N 081' 40.493' W �J� _ 2/3/2022
6.Is(are)the well(s):41'ermanent or ❑Temporary Signature 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 01C.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 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.SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface:440 (R•) Submit this GW-1 within 30 day§of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
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) 15 Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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