GW1-2022-08508_Well Construction - GW1_20220513

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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 385 ft.
ft. ft. I I
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER if a Iicable
Russell Well Drilling, c FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft. 39 rt 6.25 j In SDR21 PVC
/� '16.INNER CASING OR.TUBING eothermal closed-loo -
2.Well Construction Permit#: 3 22. 4(0 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: 17.SCREEN.
FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt• 20 ft 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 R•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG{attach additional sheets if necessary)
❑Geothermal FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 34 fL Dirt
4.Date Well(s)Completed: 3-29-2022 Well ID# 34 ft- 385 ft- Rock
5a.Well Location: ft. ft
Neill Belk ft ft.
Facility/Owner Name Facility ID#(ifapplicable) % ft MAY 15 202
122 Ideal Drive, Mooresville, NC 28115 ft•
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:
(if well field,one lat1l0ng is sufficient) 22.Certification:
35' 36.362' N 080' 48.560' W 4/14/2022
6.Is(are)the well(s): WPermanent or ❑Temporary St afore of Certifi ClW 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 I`JNo 15A 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:
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 depths ifdifferent(example-31Q200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air
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) 50 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Cup E
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water ResourcesF Revised 6-6-2018
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