GW1-2022-03816_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I 1
1.Well Contractor Information: 1
Chris C Russell 14:WATERZONES.
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft. 445 ft- 1
ft. ft.
NC Well Contractor Certification Number
Inc. 15.OUTER CASING for mu1H-cased wells OR LINER if a licable
Russell Well Drilling, c FROM TO DIAMETER i THICKNESS MATERIAL
Company Name 0 ft. 85 ft. 16.25 .' in SDR21 JPVC
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#• n/a FROM TO DIAMETER THICKII'ESS 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
RIAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
❑hri ation []Wells>100,000 GPD FROM TO 6IA'r'F RML EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormrwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20,DRILLING LOG attach'additionel'sheets,if'necessar) "
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.)
0 ff. 80 ft- Dirt
4.Date Well(s)Completed: 03-05-2022 Well ID# 80 ft' 445 ft• Rock
5a.Well Location: ft. ft
Zack Lowman ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 5 ;,
1734 Smyre Farm Rd, Newton, NC 28658 ft. ft. a
Physical Address,City,and Zip ft. ft. A ..
Iredell 21.REMARKS . ,
County Parcel Identification No.(PIN) ' _ 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtification:
35' 38.176' N 081' 11 .799' W 3/15/2022
6.Is(are)the well(s): Wermanent or ❑Temporary ature 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 ItNo 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. 1
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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:445 (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2@100�
24a. For All Wells: Original form�to Division of Water Resources (DWR),
10.Static water level below top of casing:4 (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 Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 departmIent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 3 Method of test•Ai r Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018