GW1-2022-09312_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZO1NES
Well Contractor Name FROM TO DESCRIPTION
3254 A 50 ft. 185 ft•
fL ft.
NC Well Contractor Certification Number 15 OUTER CASING for;multi-cased wells)'OR I INER if.a"'licalile
Russell Well Drilling, Inc. FROM TO DLIMETER TffiCKNESS MATERIAL
Company Name 0 ft 58 ft 6.25 1 t In sDR21 JPvc
16:INNER'CASINGOR,TUBING `eothermaFclosed=loo' ;' a '
2.Well Construction Permit#: 849 FROM I TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): fL ft' In.
Water Supply Well: 17:SCREEN s• .. - .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g ft ;n•
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:;GROUT
❑Irri ation ❑Welis>100,000 GPD FROM TO rt MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Grout Poured
❑Monitoring ❑Recovery fL ft.
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation ry r
19:SAND/GRAVEL'-PACK if.a Gcable, .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. it,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING`'OG ettacti-additioiial§heetd if iiecesss
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
0 ` 53 ft. Dirt
4.Date Well(s)Completed: 9-10-22 Well ID# 53 " 185 ft- Rock
5a.Well Location: fL fL {`
Jeff Beck
Facility/Owner Name Facility ID#(if applicable) ft. ft. O C T 0 U 202
2226 Flint Branch Rd, Lenoir, NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft. ,;e J
Caldwell 21 REMARKS',
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. rtification:
36' 11.651' N 081' 57.335' Wez4-'ae�-
9/30/2022
6.Is(are)the well(s): IDPermanent or ❑Temporary Signature of Certified well ontractor 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 15A 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:
S: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: 185 (fL) 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 2@I00')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
It.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground hijection 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 producln2 over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 20 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-161
13b.Disinfection type:.HTH Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018