GW1-2022-10286_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES
Well Contractor Name 60OM ft. 3 TO 85 ft, DESCRIPTION
3254 A fL ft.
NC Well Contractor Certification Number 15 OUTER CASING for`millfl cased wells OR LINER.If a 'licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 74 H- 6.25 1n SDR21 JPVC
16i;INNER'CASINGiUR.TUBING e6therriialcloed-1 soo " .
2.Well Construction Permit#: W4 90 FROM I To I DIAMETER I 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. ft. 1n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic ft, ft, in.
❑Geothermal(Heating/Cooling Supply) [#Residential Water Supply(single) g• g, in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 1&+GROUT }
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19'SAND/GRAVEL'.PAGK-'ifs licable,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20sDRILL7NGLOG attacfi'additioualsheetslif-riecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soiltrock tM givin size,etc.
0 ft- 69 ft. Dirt
4.Date Well(s)Completed: -15-22 Well ID# 69 ft. 385 ft- Rock
5a.Well Location: fL fL
Devan &Candace Rogers fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Ai-
rr
71 Old Bridge Rd, Taylorsville NC 28681 ft. ft. IyuVj
Physical Address,City,and Zip
fL ft.
Alexander 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.C •flcation:
35' 50.395' N 081' 11.120' W X J 10/24/2022
6.Is(are)the well(s): *Permanent or ❑Temporary Signature of Certified Well IlSontractor 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 01C.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 I 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: 385 (ft.)
For multiple wells list all depths if different(example-3@200'and 1@100') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: 60 ( ) 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
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
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
i
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 u Method of test:Air
13b.Disinfection type: HTH Amount: 1 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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