GW1-2022-10336_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 so ft. 425 h•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multl-ra wells OR LINER if cable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 56 ft 6.25 1n SDR21 JPVC
Company Name
Ili.INNER CASING OR TUBING eother al closed-1
2.Well Construction Permit#: 854 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.
Water Supply e : 17.SCREEN
pp y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipab?ublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) GlResidential Water Supply(single) ft• ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IIri tion []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:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Ka Ucable
❑Aquifer Storage and Recovery Cl 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 Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wit/ruck type,gmin size,etc.)
0 e. 51 rt. Dirt _
4.Date Well(s)Completed: 9-13-22 Well ID# 51 ft. 425 ft. Rock
5a.Well Location: ft. tt.
William Jordan U t IV ED
Facility/Owner Name Facility ID#(if applicable)
rt. rt.
4826 Low Valley Way, Lenoir, NC 28645
Physical Address,City,and Zipura
ft. ft. 1t110fR e3 t)1 �f ,
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.Certification:
35' 89.201' N 081' 65.359' W 10/3/2022
6.Is(are)the well(s):�DPermanent or ❑Temporary Siatature 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 OL) 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@100�
10.Static water level below top of using: 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(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI r Drilled
24c.For Water 5u and Oven-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmen health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinp over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 12 Method of test: Ai r D ri I I e d Permmt Program,1611 MSC,Raleigh,N 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018