GW1-2022-06549_Well Construction - GW1_20220511

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-- - WELL CONSTR06TION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14..WATER ZONES
Well Contractor Name FROM TO IDFSCRIPTION
40 f� 445 ft•
3254 A ft i
NC Well Contractor Certification Number 15.OUTER CASING fei.muld cased wells OR LINER('if a licable
Russell Well Drilling, Inc. FROM TO IDAAMETER THICKNESS MATERIAL
0 fL 85 rt 6.25 In SDR21 PVC
Company Name 16.rMR CASING OR TUBING(geothermal closed-ioo
2.Well Construction Permit# n/a FROM TO DIAMETER THICKNNFSs MATERiAt
List all applicable well construction permits(ce.WC,Catoty,State•Variance•etc.) lt. ft. in-
3.Well Use(check well use): fL fl, i-
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSUM 'THICKNESS MATERIAL
&BAgricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) fL ft.
❑Industrial(Commercial ❑Residential Water Supply(shared) 18.GROUT
OIrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: 0 ft. 20 It- Grout Poured
❑Monitoring ❑Recovery fL fL
Injection well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a licabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL r EMPLACEMFWr METHOD
❑Aquifer Test• ❑Storrnwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII1liYGLOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCREMON color,hardness,solurock a grnin size eta)
0 IL 80 ft- Dirt
4.Date Well(s)Completed: 03-05-2022 Well 1D# 80 % 445 ft- Rock
5a.Well Location: ft. ft.
Zack Lowman ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAY 1
1734 Smyre Farm Rd, Newton, NC 28658 ft. ft.
Phveiral Address;City,and Zip ft ft. 00
4a W b Q- 21.REMARKS
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, rtification:
35' 38.176' N 081' 11.799' W e. 3/15/2022
6.Is(are)the well(s): Wermpnent or ❑Temporary Mbrnature of Certified Well Contractor Date
Bp signing this form,I hereby certh,that the wens)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No /SA 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 of the of this record has been provided to the uell ouster.
repair under#11 remarks-section or on the bark 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 I 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.SUBMMAL INSTRUCTIONS
9.Total well depth below land surface:445 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 1®1001
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifws ater level is above casing,use Static water level below top of casing: (R•) information Processing Un�it,1617 MSC,Raleigh,NC 27699-1617
If "+"
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 hea i lth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD:Copy to DWR,CCPCUA
TF
Permit MSC;Raleigh, 27699-1611
13a.Yield(gpm) 3 Method oftest•Air Drilled
13b.Disinfection type: HTH Amount: 1 1/3 cup
I
Form OW-1 North Carolina Department of Enviroamental Quality-Division of Water[Resources Revised 6-6-2018
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