GW1-2022-08521_Well Construction - GW1_20220511

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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. 345 ft.
fL ft I'
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER if'a'Gcable
Russell Well Drilling, C FROM TO DIAMETER ! THICKNESS MATERIAL
0 ft- 63 ft- 6.25 1 in. SDR21 JPVC
Company Name
322675 16.INNER CASING OR TUs1NG ertthcrmaltlosed-loo
2.Well Construction Permit#: FROM I 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): fL I It, in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) giResidential Water Supply(single) ft. ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
❑lTi ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Grout Poured
❑Monitoring ❑Recovery
Injection Well: fL M
❑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 M It.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionidsheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 58 ft- Dirt
4.Date Well(s)Completed: 4-4-2022 Well ID# 58 ft. 345 f• Rock
fL
5a.Well Location: fL
Aaron & Heather Harkey ft. k•
Facility/Owner Name Facility ID#(ifapplicable) fL M
152 Orchard Farm Lane, Mooresville, NC 28117 ft fL
Physical Address,City,and Zip ft. ft.
I red el l 21.REM ARKS
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.Cc ifieation:
35' 38.740' N 080' 52.812' W - 4/9/2022
6.Is(are)the well(s): APermanent or ❑Temporary Siglrlffure of Certified Well Contractor Date
By signing this form,I hereby cent that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 1 SA 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 ofthis 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: 345 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ii different(example-3@200'and 2@100')
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) 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 Dulled
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) 1 Method of test: i r
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 Resources Revised 6-6-2018
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