GW1-2021-02700_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DhSCRL rl ION
Well Contractor Name
3254 A 60 ft 285 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAaETER THICKNESS MATERIAL
Company Name 0 ft- 85 ft- 6.251 i" SDR21 PVC
0384 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.) ft. ft. in.
3.Well Use(check well use): tt. [t. in.
Water Supply W¢Il: 1F7RO SCREEN
TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft,
Industrial/Commercial OResidential Water Supply(shared) 1R.GROUT
Illl ah011 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
Monitoring DRecovery
Injection Well:
ft. ft.
_ Aquifer Recharge DGroundwatcr Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTTON color,hardness soft/rock t rain size etc.
0 ft. 80 ft. Dirt
4.Date Well(s)Completed: 5-26-2021 well ID# 80 f`• 285 R. Rock
5a.Well Location:
David Shaak-Joan Morri: Boyce Galiher ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Gunter Hill Rd, Boomer, NC 28607 ft. ft.
Physical Address,City,and Zip
Wilkes 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22. rtifieation:
36' 05.283' N 081' 14.605' W
X?4�� 7-26-21
6.Is(are)the well(s)oPermanent or Temporary tgnature of Certified Well Contractor Date
By signing this form.I hereby certifv that the wetl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/ftluv is a repair,fill nut known well c•onsn•uc•tion 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:
R.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-I 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: 285 (tt•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Est all depths ifdiffit•ent(example-3(a)100'and 2(a)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 1.," 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection 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) 10 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 form within 30 days of
13b.Disinfection type: HTH Amount: 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