GW1-2022-08591_Well Construction - GW1_20220513

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPT ION
1 00 ft- 645 R•
3254 A fL f
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 139 ft- 16.25 f in SDR21 JPvc
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 0580 W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,etc) ft. ft. in,
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fL in:
❑Geothermal(Heating/Cooling Supply) pResidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK itapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL M
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additioniil sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 ft' 34 fL Dirt
4.Date Well(s)Completed: 4-6-2022 Well ID# 34 fL 645 fL Rock
5a.Well Location: fL fL
Dave & Natalie Webb fL ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
1590 Buck Mtn. Rd, Purlear, NC 28665 ft. ft.
Physical Address,City,and Zip
ft. ft.
Wilkes 21.REMARKS
County Parcel Identification No.(PIN) DYAWBOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.r�YIWL)
fieation:
35' 11.981' N 081' 22.389' �, 4/19/2022
)ca�.��
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !]No 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 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 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: 645 (f>) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(�00'and 1@100')
10.Static water level below top of casing: 100 (ft) 24a. For All Welts: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
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
Permit Program,1611 MSC,Raleigh,'NC 27699-1 6 1 1
13a.Yield(gpm) 3 Method of test:Air
s
13b.Disinfection type: HTH Amount: 2 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018