GW1-2022-03822_Well Construction - GW1_20220404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 200 ft- 645 ft-
ft. ft.
NC Well Contractor Certification Number Inc. 15:OUTER CASING for multi-cased'wells OR LINER if a livable
Russell Well Drilling, c FROM TO DIAMETER' THICKNESS MATERIAL
0 ft• 76 ft 6.25 i° SDR21 PVC
Company Name
16.INNER CASING AR TUBING eofheFinal closed-loop)
2.Well Construction Permit#: 753 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
1 Well: 17.SCREEN-
Water Supply y FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 'I8.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL 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 r20.DRILLING LOG(attuch additional sheets if necessary)'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.)
0 fr. 71 ft- Dirt
4.Date Well(s)Completed: 11-11-2021 well ID# 71 ft. 645 ft- Rock
5a.Well Location: ft. ft.
Dauria, David & Lori
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4820 Low Valley Way, Lenoir, NC 28645 ft. ft. �
Physical Address,City,and Zip ft. ft.
Caldwell (21.REMARKS . APR
-
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' 53.597' N 081' 39.275' W A 3/7/2022
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified ell 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 dNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair corder#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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 645 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 200 (ft.) Information Processing Unit, MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
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 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(gpm) 2 Method of test: i r
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018