GW1-2022-08770_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris C Russell `14.'WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft 645 ft
ft. ft. j
NC Well Contractor Certification Number 15:,OUTER`CASING`for:multitased wells'OR LINER if a `livable
Russell Well Drilling, Inc. FROM TO DIAMETER TIffM,SS MATERIAL
Company Name 0 ft• 91 ft 6.25 ! in SDR21 JPVC
P907 36(:: 'T INNER:GASINGORUBING ''eotherm -lo eiclosedo" s:
W
2.Well Construction Permit#: P9 FROM TO DIAMETER TWCIINESS 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.
1.7!SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft, in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I GROUT ,
01ni ation ❑Wells>100,000GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'-PACK,if.a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
❑Geotbetmal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets'if aecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size etc
0 ft. 86 ft Dirt
4.Date Well(s)Completed: 8-12-22 Well ID# 86 ft 645 ft Rock '
5a.Well Location: ft ft. 9-
James Wright ft fL M
Facifity/Owner Name Facility ID#(if applicable) ft fL S 1_P U �, h
2891 Wildwood St, Hudson, NC 28638 ft ft.
Physical Address,City,and Zip ft. ft. D�Ad�fk30(3
Caldwell 21:REMARKS .
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, ertifieation:
35' 83.145' N 081' 45.860' W 9/2/2022
6.Is(are)the well(s): IMPermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisjorm,I hereby cent that the well(s)was(were)constructed in accordance with
7.Is this a repair t0 an existing well: ❑Yes or MNo 15A NCAC 01C.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 ofthe 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: 645 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@200'and 2@100')
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater 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
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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) 5 Method of test Air
13b.Disinfection type: HTH Amount: 1 2/3 cup
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Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018