GW1-2022-10297_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name
3254 A so ft. 390 f=•
ft. ft.
NO Well Contractor Certification Number 15.0=R;CASINCr f6r T!4111�a,e(wells)OR LINER`if a 1I6ble -
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATEPJAL
Company Name 0 ft 1124 ft 6.25 1 In SDR21 JPvc
368 16INNER CASING OR TUBING 'eotherma
4 8 l closed lob fir
2.Well Construction Permit#: 368 FROM TO DIAMETER THICKNESS MATERUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN.
pp y FROM TO DIAMETER" SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) 47Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 IL Grout' Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEIrPACK if:a "hcable
❑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:DRIVLING`10G ii hiadditiouelsheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock in size,etc
0 =_ 119 fr. Dirt
4.Date Well(s)Completed: 10-6-2022 Well ID# 119 fL 390 fL Rock
ft. ft.
5a.Well Location:
Sandra McCurdy Boyce Galliher ft. ft. I
Facility/Owner Name Facility ID#(ifapplicable) ft. R•
8895 Spring Meadow Dr, Hickory, NC 28601 ft. ft. NOV 1 Lozz
-
Physical Address,City,and Zip ft. ft. Uf14
Burke 21-REM ARKS.
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:
35' 75.727' N 081' 43.052' W &r=::�
10/10/2022
6.Is(are)the well(s): RPermanent or ❑Temporary Signature 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: []Yes or InNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 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: 390 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
G 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V 0 (R•) Information Processing Unit,1.617 MSC,Raleigh,NC 27699-1617.
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air
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
138.Yield Wm) 140 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