GW1-2022-07094_Well Construction - GW1_20220801

WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
1.Well Contractor Information:
Chris C Russell WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 245
% ft.
NC Well Contractor Certification Number 15.OUTER.CASING'(fok_f!!L,=s e d wells fO L Rk1f_!Ji6kb1e)
FROM TO TER _Tffl= MATERIAL
Russell Well Drilling, Inc. 0 IL 187 ft- 16.98 : in ISDR21 JPVC
Company Name A 6.INNER:CASING'ORT INGI(ge6thermal closed­ldop);��
2.Well Construction Permit#: 3300 18 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft It. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well:
FROM:SCREEN..TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) Ellesidential Water Supply(single) ft. ft.
01ndustrial/Commercial oResidential Water Supply(shared)
IS.I.GROUT :.-
OIrri--alion OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
OMonitoring ORecovery ft. M
Injection Well: %
OAquifer Recharge 0 Groundwater Remediation 19i SAND/GRAVEL PACK(if supo I HcAble)
OAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
(]Experimental Technology D Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer i.111120.DRILLING LOG(AttikhAdditiodil sheets if iffetessafy)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sohlrock type,gnin stzc,etc.)
0 ft- 82 ft- Dirt
4.Date Well(s)Completed: 7-19-22 wcIlID# 93 ft- 245 It Rock
5a.Well Location: ft. ft
Jeff Cash ft. ft V I=
Facility/Owner Name Facility ID#(if applicable) ft. ft. AUG a 1 2W2
120 Cash Lane, Statesville, NC 28677 ft. ft.
Physical Address,City,and Zip ft. ft. IrWorvn n Proc3ec4ng Unk
Iredell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35' 44.697' -N080' 49.687- W 7/27/2022
Sig
6.Is(are)the well(s): IMPermanent or []Temporary nature of Certified Well Contractor Date
By signing thisform,lhereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or MNo 15A NC4C 02C.0100 or 15A NC4C 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 well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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-I 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: 245 Submit this GW-1 within 30 days of well completion per the following:I
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
10.Static water level below top of casing: 60 24a. For All Wells: Original f6rm to Division of Water Resources (DWR),
- Information Processing Unit,1617!MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6.2 5r (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUQ
Program,1636 MSC,Raleigh,NC�27699-1636
12.Well construction method:Air Drilled i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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) 25 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource s Revised 6-6-2018