GW1-2022-01792_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD(GW-0 For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 40 ft- 185 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulNtased wells OR LINER If a licab e
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 38 ft.
6.25 In- ISDR21 JPVC
Company Name
311773 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#' FROM TO DIAMETER I THICKNESS L MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. tn•
3.Well Use(check well use): ft• ft.
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) [OResidential Water Supply(single) ft. ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrr ation ❑Wells>t00,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. tL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Battier 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/rock Pipe,grain sine,etc.)
0 ft. 33 fL Dirt
4.Date Well(s)Completed: 12-29-2021 Well ID# 33 ft. 185 fL Rock
5a.Well Location: ft. fL
John McCormick Piedmont Quality Builders rt. ft. -
Facility/Owner Name Facility ID#(if applicable) ft. fL
186 Watering Trough, Statesville, NC 28677 ft. fL ."awaLkin pmamw
Physical Address,City,and Zip
rt. ft.
Iredell 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.Cert cation•
35' 44.196' v 080' 53.473' W ;64"a')
1/10/2022
6.ls(are)the well(s): 17Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wills)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It No 1 SA 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 1 GW-I 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: 185 (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@1001
40 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"+"
It.Borehole diameter: 6.25 (ill.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)2C Method of test:AI r
13b.Disinfection type: HTH Amount: 1/2 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018