GW1-2022-09286_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONEs. . x Ls=
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft- 325 ft•
rt fL
NC Well Contractor Certification Number 15:-OUTER:CASING f&i; ulN-cased wells`OR+I INER'if,'a`-'licatile,
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 96 ft.
6.25 In SDR21 PVC
Company Name
325754 ]6:;INNER:CASING`OR;TIIBING eotherineL'closea hiit`'s ;;
2.Well Construction Permit#: FROM 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): ft. M in.
17 SCREEN
Water Supply Well:
FROM TO ss DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 48:<GROUT
❑lrri ation ❑Wells>t00 000 GPD FROM TO ' r.MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVELaP.ACK;if.e"""lic`able T_Y w., k
❑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 Loop) ❑Tracer 20}.DRILL1NGtLOG.a`ttach'additionel dheets ifnecessa ljx
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/racktype, rnIa s etc.
)0 rt. 91 ft. Dirt
4.Date Well(s)Completed: 8-25-22 Well ID# 91 ft- 325 fL Rock _
Sa.Well Location: ft. a `. 1"` r E
s E
Patrick Perry Larry Munday Builders ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. OCT
ft. ft.
586 Massey Deal Rd, Statesville, NC 28625
Physical Address,City,and Zip ft. ft.
219'REMARKS
Iredell '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.C •nation:
35' 80.246 N 80' 99.447 W 9/23/2022
6.Is(are)the well(s): 18Permanent or ❑Temporary Signature of Certified Well Cbntractor 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 02C.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: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifeli ferent(example-3 200'and 2@100')
10.Static water level below top of casing:40 (fL) 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
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy lio DWR,Underground Injection Control(IUC)
Air Drilled Proms,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 producini over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of
20 test:Air Drilled PetmttProgram,1611 MSC,Raleigh,NC27699-1611
I
13b.Disinfection type: HTH Amount: 1 cup
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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