GW1-2023-02333_Well Construction - GW1_20230331

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. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL.
0 ft 85 f- 16.25 i" SDR21 JPVC
Company Name
329102 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS IMATERIAL
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.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
❑lrri 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. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM To DESCRIPTION(color,hardness
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) soi0rock Frain size,etc.)
0 It. 80 ft. Dirt -- - - -
4.Date Well(s)Completed: 3-15-2023 Well ID# 80 ft. 565 R• Rock
Sa.Well Location: ft. ft. D D ,1
Americas Home Place " `t
Facility/Owner Name Facility ID#(if applicable) fL
206 Harbor Watch Dr. Statesville NC 28677 ft. ft.
Physical Address,City,and Zip ft. ft.
Iredell 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' 695.56' N 80'97.531' W 3/20/2023
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 ONo 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 ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: 565 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 r@200'and 2Q1000
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft) Information Processing Unit,1617 MSC,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)
,.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
13a.Yield(gpm)4 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/3 CUP
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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