GW1-2022-08788_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- 325 ft-
NC Well Contractor Certification Number
15.OUTER CASING for multi=cased wells)0
Russell Well Drilling, Inc. FROM To
DIAMETER
MATERIAL
Company Name 0 ft. 55 6.25 in
1 I JPVC
. SDR21
I&INNERCASINGOR:TUBING(2e4thermal closed4bia
2.Well Construction Permit#: n/a 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 it. in.
Water Supply Well: 47.:SCREEN.i FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft• in.
oGeothermal(Heating/Cooling Supply) ©Residential Water Supply(single) -ft. ft.
Olndustrial/Commercial OResidential Water Supply(shared) 7-A r o-' ­
,Roui,
01nigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 20 fq Grout Poured
oMonitoring ORecovery ft. fL
Injection Well: ft. ft.
OAquifer Recharge CGroundwater Rentediation
�49 SAND/GRAVEL PACK!if applicable)
0Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test oStormwater Drainage ft. fL
DExperimental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer MDRILLING LOG(attac
ID thermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardoe&%soil/rack VM in sin,etc.)
0 ft' 50 fL Dirt
4.Date Well(s)Completed: 6-2-22 well IDIj 50 325 ft- Rock
fL ft 'V' LZ[-J
5a.Well Location:
Kirt Anderson ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft
239 Kinder Rd, Harmony, NC 28634 ft. ft. Una
Physical Address,City,and Zip ft. ft.
Iredell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.C
35' 92.584' -N080' 75.019- W 8/9/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): JiPermanent or OTemporary
By signing thisform,I hereby certify that the well(s)was(ware)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or MNo 15A NCAC 02C.0100 or 15A NC4C 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.Sitediagram or additional well I I 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: 325 Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifilifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 -(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,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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018