GW1-2022-08787_Well Construction - GW1_20220909

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 60 ft- 419 ft I
ft ft
NC Well Contractor Certification Number OUTER CASING CASING f6k:mulg4ified wells'OR�:INER rf a Ilceble
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 68 ft 6.25 ! in SDR21 JPVC
325874 16:INNER CASING'OR TUBING eo'thettial closed-loo a
2.Well Construction Permit#: FROM TO I DIAMETER HHICINESS 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) IlResidential Water Supply(single) ft ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) -ili—
GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. M
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19+SAND/GRAVEL PACKtifa 7icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed hoop) ❑Tracer 20..DRILIANGLOG attac'additiouaisbeetsaf,riecessa'°
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solitrock type,prain size,etc.
�1
0 rt• 63 fL Dirt
4.Date Well(s)Completed: 7-27-22 Well ID# 63 ft 419 ft. Rock
5a.Well Location: ft ft.
Shelby Best ft ft. K� � _%5
Facility/Owner Name Facility ID#(if applicable) It. fL
121 Bess Rd, Statesville, NC 28625 ft ft.
Physical Address,City,and Zip ft ft Ci; 1%�i :� N D•
Iredell 2LRFMARKS,C: J>' v
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.C frcation:
35' 92.873' N 080' 91 .532' . •W r(JKI� 8/9/2022
6.Is(are)the well(s): OPermanent 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 ONo I SA NCAC 02C.0100 or I SA 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 ofthe of this record has been provided to the well owner.
repair under#11 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:419 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
10.Static water level below top of casing: 60 (th) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
It'.Borehole diameter: (in.)
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC!27699-1636
12.Well construction method: 24c.For Water Supply and Opert-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 Wm) 100 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018