GW1-2022-06337_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 120 It- 425 ft.
ft. ft.
NC Well Contractor Certification Number
Inc. 15.OUTER CASING(for multi-cased e�ells OR LINER if a licable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 131 ft- 6.25 in- ISDR21 JPVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 878 FROM TO I 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. ft. in•
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 If- 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 rt. 126 ft. Dirt
4.Date Well(s)Completed: 3-2 1-2022 Well ID# 126 ft- 425 ft- Rock
5a.Well Location: ft ft
Laura Lewis Todd Triplett ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft
4864 White Oak Way, Lenoir, NC 28654 fr.
is E9
Physical Address,City,and Zip ft. ft.
Caldwell 21.REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification.
35' 54.589' N 081' 29.448' W e 6/15/2022
6.Is(are)the well(s): pPermanent or ❑Temporary Signa a of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0/00 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 of the ofthis 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 if necessary.
drilled: 24.SUBMPTTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells List all depths if different(example-3 a200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 (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 department 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(gpm) 12 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018