GW1-2022-08771_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES =,
Well Contractor Name FROM TO DESCRIPTION
3254 A . 120 ft- 405 ft-
fL ft.
NC Well Contractor Certification Number
IS;:OUIER EASING for.'rii6lti cased wells OR:LINER;its `licatile
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 91 ft 6.25 1n• SDR21 JPVC
Company Name
16S INNER C-ASING 012'<TUBING eot7ieOmal closedaoo'
2.Well Construction Permit#: 818 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): fL ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [BResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
o:,1
Olrrijzation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f° 20 ft Grout
❑Monitoring ❑Recovery ft. %
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.iSAND/GRAVEL'PACK_'d.a`'liceble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20i'DRR:LINGLOG:atti aaiutio5iel sheet§?ifiiecessa
+
❑Geothermal(Heating/Cooling Return)
TO DESCRIPTION color hardness,soilfrock e, in size,etc.) ❑Other(explain under#21 Remarks) 0 fL 86 ft. Dirt
4.Date Well(s)Completed: 8-1 1-22 Well ID# 86 ft- 405 fL ROCk n_7
Sa.Well Location: ft.
Mark McGinnis fQ ft. spp o y 20ZZ
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2880 NC Hwy 90, Lenoir, NC 28645 ft. ft in�v4 ' ',^"'
MmmoG
Physical Address,City,and Zip fL ft.
caiaWeii >21:REMARKS
County Paruel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertitication:
35' 89.495' N 081' 36.622' W XV - 8/12/2022
6.Is(are)the well(s): liPermanent or ❑Temporary Signature of Certified well 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 MNo 1 SA NCAC 02C.0100 or 15A NCAC 01C.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:405 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@100)
10.Static water level below top of casing: 120 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,use-+" I
11.Borehole diameter:
6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,.
Program,1636 MSC,Raleigh,NCI27699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Opeu-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) 10 Method of test:Air
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTH Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018