GW1-2022-07096_Well Construction - GW1_20220801

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 60 It- 385 ft•
ft ft. i
NC Well Contractor Certification Number M OUTER CASING foi multi cased w�,Ols OR LINER' if>a "licatile
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name fe
0 121 ft 6.25 In SDR21 PVC
323340 =16;INNER'C9SING;ORTUBING" eottierrirel?closed-loo
2.Well Construction Permit#: FROM TO 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.
Water Supply Well: FROM ENI TO DIAMETER{ SLOT SIZE ITHICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. it. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑lni ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL'PACK•:if.a""liceble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fa ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 920 DRILL7NG',LOG attictiadditional sheet§iifaiecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rack type,grain size etc
0 ft- 116 fL Dirt
4.Date Well(s)Completed:4-10-22 Well ID# 116 ft- 385 ft- Rock
5a.Well Location: ft ft
Terrance Hamby ft. ft. AUG a _
Facility/Owner Name Facility ID#(if applicable) % ft.
115 Hicks Rd, Statesville, NC 28625 ft. ft Af=9 uflm
Physical Address,City,and Zip ft. ft.
Iredell 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' 91.197' N 080' 94.963' W �� 7/29/2022
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature 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 15No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis 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 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: 385 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all.depihs if different(example-3Q100'and 2@100)
10.Static water level below top of casing: 60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/fwater level is above casing,use"+^ Information Processing Unit,1617jMSC,Raleigh,NC 27699-1617
6.25 246.For Infection Wells:Copy tjo DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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) Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
i,
13b.Disinfection type: HTH Amount: 1 cup I�
f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018