GW1-2022-09321_Well Construction - GW1_20221007

i
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- 485 ft,
ft. ft.
NC Well Contractor Certification Number 15S OUTER;CASING for:multi casedwells OR'LINER'ifa`"lIcable
Russell Well Drilling, Inc. FROM TO DIAMETER= TRICKINESS MATERIAL
Company Name 0 ft. 62 ft- !6.25 in.
SDR21 JPVC
0621 W 16:1NNEWCASING:OR`TUBING "ebthevmeCclosed-loo`' ,_t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I 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.
Water Supply Well: d7'.SCREEN
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
❑Monitoring ❑Recovery ft, ft.
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,'SAND/GRAVEL PACK`if.a""licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 30:DRILLINGI OG`attach additional sheets if necessa '
❑Geothermal(Heating/Cooling Return) ft. 5
) ❑Other(explain under#21 Remarks) FROM 7 DESCRIPTION mtoq saran soi0rock a in size etc.
7 fL Dirt ;
4.Date Well(s)Completed: 8-1 7-22 Well ID# 57 fL 485 ft• Rock
5a.Well Location: fL ft.
Tod & Irene Falter ft. f°
Facility/Owner Name Facility ID#(if applicable) ft
Lake Point Dr., Lot# 14 &15, Boomer, NC 28606 ft. ft.
Physical Address,City,and Zip 11L ft
OCT 0 7-2022
Wilkes 21 REMARKS
Cc.1 li 1. 4•/
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.Certification:
36' 11.399' N 081' 27.444' W 1 9/9/2022
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signs o Certified Well Co tractor 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 ItNo 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 ofthe 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-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: 485 (ft.) 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@I00D
10.Static water level below top of casing: 60 O 24a. For All Wells: Original form,to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter. 6.25 (in.) 24b.For Injection Wells:Copy toy DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled I
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 over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5 Method of test:Air
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I� Revised 6-6-2018