GW1-2022-03762_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
Chris C Russell 14i WATER ZONES
Well Contractor Name FROM ft. TO ft DESCRIPTION
3254 A 80 385
ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DLIMETEIt THICKNESS MATERIAL
Company Name p ft. 96 ft. 16.25 ' in SDR21 JPVC
0330W 16.INNERCASINGORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernnits(i.e.UIC,County,State,Variance,etc.) ft. ft. in•
3.Well Use(check well use): fL It
in-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft ini'
❑Geothermal(Heating/Cooling Supply) QlResidential Water Supply(single) ft ft, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft' Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
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)'
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
p ft. 91 ft. Dirt
4.Date Well(s)Completed: 12-21-2021 well ID# 91 fl• 385 fr. Rock
5a.Well Location: ft. ft.
Ed McConnell ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
1918 Walshtown Rd, Boomer, NC 28606 ft. ft
Physical Address,City,and Zip ft. ft.
Wilkes -21.REMARKS '
I
County Parcel Identification No.(PIN) �'•"^t
5b.Latitude and longitude in de rees/minutes/seconds or decimal degrees: " ' L`�i 1
g� g g
(if well field,one]at/long is sufficient) 22.Certification:
36' 05.412' N 081' 14.717' W 2/14/2022
6.Is(are)the well(s): LiPermanent or ❑Temporary Signature of Certified well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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:
S.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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 385 (ft) Submit this GW-1 within 30 days;of well completion per the following:
For multiple wells list all depths ifeli ferent(example-3 a200'and 2@100D
10.Static water level below top of casing: 80 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 NISC,Raleigh,NC 27699-1617
if waxer level above casing,use op
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
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
gh,NC 27699-1611
13a.Yield(gpm) 15 Method of test: i r Permit Program,1611 MSC,Ralei
13b.Disinfection type: HTH Amount: 1 Cut•'
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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