GW1-2023-02018_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Chris C Russell -14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft. 325 ft, ?.
ft. ft. ' t
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL •-Company Name 0 fA 38 ft 16.25 1 is SDR21 JPVC
0682 W 16:INNER CASING OR TUBING(eothermal closed-loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERAL
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 Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -' 1
01ni ation ❑Wells>100,000 GPD FROM TO MATERL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 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. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additibrial'sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0"
TO DESCRIPTION(color,hardness,soilfrock type, rain size,etc.)
ft. 33 ft. Dirt
4.Date Well(s)Competed: 02-15-2023 Well ID# 33 1 325 ft• Rock
5a.Well Location: ft ft•
ft. ft
GP1 Trust John Miller P�-
_�'
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
Beaver Creek Rd, Boomer, NC 28603 ft. ft. r�
Physical Address,City,and Zip ft. ft. i(t�"�ii:3;S^� : '>' :C•. 4;t'7;:
Wilkes -21.REMARKS "i:J!i;X4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
36' 04.993' N,081' 32.431' W j
2/22/2023
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well ontractor 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 ItNo 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 ofthe 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: 325 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3@200'and 2@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,1617MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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) 15 Method of test:Air Permit Program,1611 MSC,Raleigh,;NC 27699-1611
13b.Disinfection type: HTC Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018