GW1-2022-10335_Well Construction - GW1_20221114

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 100 ft• 425 k
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If Icabk
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 105 it- 16.25 In SDR21 JPVC
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#• 957 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. ft. In.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) k. k•
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ObTiRation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD 3r AMOUNT
Non-Water Supply Well: 0 ft' 20 Grout Poured
❑Monitoring ❑Recovery ft. k.
Injection Well:
ft. ft.
❑Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑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.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soli/mck rain size,etc.
0 n 100 it. Dirt
4.Date Well(s)Completed: 9-12-22 Well ID# 100 IL 425 fL Rock
5a.Well Location: It. it.
Bobby Myers ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. tL N O v A
High Country Rd Ext. Lenoir, NC 28645 ft. ft.
{
Physical Address,City,and Zip ft. ft. r,t a, ;,, UrltX
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.C rtification
35' 89.179' N 081' 66.379' w
� 10/3/2022
6.ls(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well .ontractor Date
4 signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or DNo ISA NCAC 02C.0100 or ISA NCAC 01C.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 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.SUBMMAL INSTRUCTIONS
9.Total well depth below land surface:425 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
10.Static water level below top of using: 100 ( ) 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(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(..Well construction method: Air D rl l ed 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 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
10 Air Drilled Permit Program,1611 MSC,Raleigh,NC 2769000 r6-I I
r1
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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