GW1-2022-10712_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 3254 A 100 ft- 565 ft. � '
ft. ft. �
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 65 ft 16.25 in SDR21 JPVC
Company Name
•W521 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): fL IL in.
Water Supply Well: FR�iREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑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: M ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK it a licable
❑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)
FROM TO DESCRIPTION color,hardness,solUrock c, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 60 ft- Dirt
4.Date Well(s)Completed: 1 0-21-22 Well ID# 60 ft- 565 It. Rock
5a.Well Location: ft. ft
Ian Archibald Mark Foy ft. ft }
Facility/Owner Name Facility lD#(ifapplicable) ft. fL DEC V 0 2022
5730 Three Forks Ch Rd Taylorsville NC 28681 ft. ft.
Physical Address,City,and Zip ft. ft. lD�-QJ 30G
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.Certification:
35' 97.087' N 081' 25.643' yr �4 11/22/2022
6.Is(are)the well(s): DPermanent or ❑Temporary Signature of Certified Welileontractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA 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 ofthis farm.
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: 565 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 1@100)
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 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)
,.
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
(Le.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 DVM CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)4 Method of test:Air � ,
13b.Disinfection type: HTH Amount: 31y CKp
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources. Revised 6-6-2018