GW1-2023-01413_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-1)' For Internal Use Only:
1.Well Contractor Information:
Chris C.Russell 14.WATER ZONES 4
Well Contractor Name FROM TO DESCRIPTION
3254 A v : .,�`J, �. r. s0 ft. 565 ft,
p ft. ft.
NC Well Contractor Certification Number FEB J 8 2023 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
CompanyName ln;o5ri �:s;;, r.- 0 ft. 71 ft. 6.25 ' In. SDR21 PVC
D11r Qiu1G 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 886 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructiai permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[]Irrigation ❑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:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑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,solltrock type in size,etc.)
0 ft' 66 fL Dirt
4.Date Well(s)Completed: 1-1 6-23 Well ID# 66 ft- 565 f- Rock
5a.Well Location: ft. ft.
Mark Omvecz John Sprinkle ft. ft.
Facility/Owner Name Facility lD#(ifappticable) ft. fL
2013 Thoroughbred Way, Lenoir NC 28645 ft. ft.
Physical Address,City,and Zip
ft. ft.
Caldwell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i£wc0 field,one lat/long is sufficient) 22.Certification:
35' 88.784' N 081' 62.387' W �� �l�L 1/30/2023
6.Is(are)the well(s): @Permanent 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 8No 15A NCAC 02C.0100 or 15A NCAC 02C.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 oftiris record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 1
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 ifdifferent(example-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft.) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 8 Method of test'Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/2 cups
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018