GW1-2023-01561_Well Construction - GW1_20230209

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 80 ft- 165 ft.
fit fit. f
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER Cif a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 55 ft 6.25 i in SDR21 JPVC
2022-7850 16.INNER CASING ORTUBING eothermalclosed-loop)-
2.Well Construction Permit#. 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. fL in.
Water.Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) F11Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 718.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: 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 R.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG attach additional sheets if necessaryy-
0Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type in size,etc.)
r�
0 ft. 50 ft. Dirt
4.Date Well(s)Completed: 12-2-22 Well ID# 50 ft- 165 ft- Rock
5a.Well Location: ft fL �� "t`4 .i-
America's Home Place ft ft 1 '��__
' 9Facility/Owner Name Facility ID#(if applicable) fit. ft '
151 Oak Point Lane, Stony Point NC 28678 ft ft. Pr,:;,-,
Physical Address,City,and Zip ft. ft.
I redell 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22. rtifteatlon:
35' 77.501' N 08'1' 09.492' W 1/30/2023
6.Is(are)the well(s): [Permanent or ❑Temporary �ature of Certified WeN 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 ONo 15A 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 ofthe ofthis record has been provided to the well oiwner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 165 (iL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 1@100�
10.Static water level below top of casing: 80 (fit) 24a. For All Wells: Original form to Division of Water.Resources (DWR),
Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 On.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
,.1 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
Permit Program,1611 MSC,Raleigh,13a.Yield(gpm) 0 Method of test:Air NC 27699-1611,
13b.Disinfection type: HTH Amount: 1/3 cup 4
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018