GW1-2022-07115_Well Construction - GW1_20220801

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft 345 ft
ft. ft.
NC Well Contractor Certification Number &OUTEWCASING fortriiulti-daseit*ells)'OR'"LINER if a ticable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATE
0 ft• .64 ft 6.25 in. SDR21 PVC
Company Name
0534 W 16JNNER:CASINGOR;TUBING `eotbe mal`dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I 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.
:SCREEN 17
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [AResidential Water Supply(single) g ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;=GROUT
01rrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 f° Grout Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19s SAND/GRAVEL PACK'if,a`liceble
❑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::attacti'additional sbeets if oecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardy soil/rock qpe,grain size etc
0 ft. 59 fL Dirt
4.Date Well(s)Completed:4-13-22 Well ID# 59 ft. 345 ft. Rock •—
5a.Well Location: ft ft �... i
John Pipes `t ft 1 7
Facility/Owner Name Facility m#(if applicable) ft ft
Prucmekwi Ur*
Hidden Hollow Rd. Wilkesboro, NC 28697 ft ft ,tjonrii�n
Physical Address,City,and Zip
ft ft.
Wilkes ..21.'REMARKS rs
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.C fication:
36' 04.169' N 081' 12.837' W 7/25/2022
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Wel Contractor Date
By signing this form,!hereby certo that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo I 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 well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 345 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdijjerent(example-3Q200'and 2Q100)
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 50 Method of test:Air
13b.Disinfection type: HTH Amount: 1 cup
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018