GW1-2021-02641_Well Construction - GW1_20210930

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
3254 A 100 f` 405 ft.
fL I ft.
NC Well Contractor Certification Number I5.OUTER CASING formulti cased wells OR LINER&if o licabI
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 f` 107 ft 6.25 in SDR21 JPVC
Company Name
W468 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.UIC,County.State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.SCREEN
Water Supply Well: r
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [']Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) za.GROUT
❑IITi ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i 19.SAND/GRAVEL PACK if applicable)
❑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 sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a in size,etc.
0 ft. 102 ft- Dirt
4.Date Well(s)Completed: 8-4-21 Well ID# 102 fL 405 ft, Rock
5a.Well Location: fL fL
Erik Smith fL It.
Facility/Owner Name Facility ID#(if applicable) ft. fL 3
10 Renee's Rocky Top Dr.Taylorsville, NC 28681 fL ft• {,eSSAl
Physical Address,City,and Zip fL fL rJ(((`,'.� Sgcx+O
Alexander 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' 55.628 N 081' 18.580' W 6� 9/10/2021
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Lv 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:405 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100')
100 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"+-
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
,.
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drll led 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield Win) 5 Method of test: I r
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S