GW1-2022-08816_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
80 ft. 445
3254 A
NC Well Contractor Certification Number
15..OUTER CASING for ells):
Russell Well Drilling, Inc. FROM I To T112MISM OFUM MATERIAL
0 ft- 179 ft- 16.25 In JSDR21
Company Name I
16i INNER CASING iOR'.T
2.Well Construction Permit#: 0672 W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
In.. .
3.Well Use(check well use): ft ft
17.�SCREEN:i
Water Supply Well: FROM TO DIAMETER I SLOT SUM I THICKNESS MATERIAL
DAgricultural [:]Municipal/Public ft. fL in.
DGeothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft. ft.
01ndustrial/Commercial OResidential Water Supply(shared)
OIrrigation OWells>100,000 GPD FROM TO -MATERIAL —EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 fr Grout Poured
OMonitoring ORecovery ft. ft.
Injection Well:
ft. fL
DAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test OStorinwater Drainage ft. ft.
OExperimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer DRIL13NG LOG(attai 'additional-sheets if Aec6sary)'
ElGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
0 ft 74 fL Dirt
4.Date Well(s)Completed: 8-18-22 - Well ID# 74 fL 445 fL Rock
5a.Well Location: ft. ft
Sam Ogilvie, Jr. ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. SEP 9 91 2022
1715 High Rock Rd, Boomer, NC 28606 ft. ft. Un,11
Physical Address,City,and Zip % ft.
Wilkes 21.REMARKS,.i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcfl field,one lattlong is sufficient) 22.Certification:
36' 06.481' _N081' 28.930- W 1 8/19/2022
— ed,�
6.Is(are)the well(s): SPermanent or OTemporary I SigEtuic 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: OYes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: I
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 445
For multiple wells list all depths ifalifferent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: —(N Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
I I.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copyito DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC'27699-1636
12.Well construction method:Air Drilled 24c.For Water Supply and Open-LoopI 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 produci over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test:Air
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