GW1-2023-02352_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 150 ft• 645 It.
ft. I It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a IIcable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 171 ft- 6.25 ISDR21 JPVC
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#• 909 FROM TO 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): ft. ft. in.
17.
Water Supply Well: FR M 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 ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fr. 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 I TO I MATERIAL JEMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑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,soittrock e. rain sin,etc.)
0 ft' 66 ft- Dirt
4.Date Well(s)Completed: 1-.I 1 3-23 Well ID# 66 ft. 645 ft. Rock
5a.Well Location: ft. ft
Stephen Graham 9
Facility/Owner Name Facility ID#(if applicable) ft. ft. [r n U
6289 Painted Ridge Trail, Lenoir, NC 28645 ft. ft. .,:_, , ;, ',,_ ._ : 3' "'
Physical Address,City,and Zip ft. ft. """' - e'
Caldwell 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.Certification:
35' 88.860' N 081 '' 69.110 W 3/7/2023
6.Is(are)the well(s): ElPermanent or ❑Temporary Signature ofCertified Well Contractor 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 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 ofthis.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: 645 (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 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 150 (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
(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) 2 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: HTC Amount: 2 Cups
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018