GW1-2021-02602_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14 WATER ZONES'
Well Contractor Name FROM TO DESCRIVI ION
3254 A
60 ft. 265 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 99 f` 1 6.25 in SDR21 PVC
316720 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) tt. fL in.
3.Well Use(check well use): ft. [[. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X Residential Water Supply(single) fL ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Grout Poured
Monitoring DRecovery ft. ft.
Injection Well:
f[. ft.
Aquifcr Rcchargc OGroundwatcr Remcdiation
-=19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSaLinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) >:
Geothermal (Heating/Cooling Return) MOther(explain under 921 Remarks FROM TO DESCRTPTION color,hardness soiUrock type,grain sirs etc.
0 ft. 94 ft' Dirt
4.Date Well(s)Completed:7-13-21 well ID# 94 " 265 ft• Rock
5a.Well Location: ft. ft.
Jeremy Plyer ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. N
115 Tucker Rd, Statesville, NC 28677 ft. ft. Ale
Physical Address,City,and Zip
redel l 2L REMARKS
County Parcel Identification No.(PIN) �10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22. rti teation:
35' 42.876' N 080' 50.269' W
� 7-27-2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified WeNContracLor Date
By signing this form.1 herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
J this is a repair,fill out known well conavuetion 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:
8.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: 265 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list till depths ifdifJerent(example-3L200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 form within 30 days of completion of well
12.Well construction method: construction 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) 15 Method of test: Air 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fotnri within 30 days of
13b.Disinfection type HTH Amount: 2/3 Ciup 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