GW1-2021-02113_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM TO DFSCRIP'1'ION
3254 A Kt: MU 0 ft. 605 ft.
ft. ft.
NC Well Contractor Certification Number O (� g021 15.OUTFWCASING for muttt-cased wells OR LINER if a licable
Russell Well Drilling, Inc. JUL i7 C I Ill. FROM TO DIA METER THICKNESS MATERIAL
Company Name on process
0 ft 61 ft• 6.25 in SDR21 PVC
Inf e(man ^'UOn 16.INNER CASING 0R TUBING(geothermal closed-too
2.Weil Construction Permit#: 767 0 Se. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,Stale, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
IndustriaVCommercial Residential Water Supply(shared) 18.GROUT
73 Irrigation FROM 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
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test o' Stormwater Drainage
J Experimental Technology Oi Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRDAANG LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRTPTTON color,hardness soiltrock type,grain size etc.
0 It- 56 ft- Dirt
4.Date Wel(s)Completed: 5-8-21 Well ID# 56 ft• 605 ft• Rock
5a.Well Location: ft. ft.
Randy Hart-Truex Moss Marlow
Facility/Owner Name Facility ID#(if applicable)
1254 Whispering Pines Ct, Lenoir, NC 28645
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' 54.121' N 081' 40.822' W
6-2-21
6.Is(are)the well(s)oi Permanent or ElTemporary Signature of Certified ell Contractor Date
By signing this form.1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well cows action information and explain the nature of the copy 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:
A.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L200'and 2@100� construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
If water level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this for within 30 days of completion of well
12.Well construction method: form within
to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Suvoly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 2/3 cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016