GW1-2023-02354_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft. 245 ft.
fit. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER d'a Ilcable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS DtATERiAL
p ft. 74 ft 6.25 1n SDR21 JPvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 994 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) fit. 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) GiResidential Water Supply(single) fit. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1ni ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. [t.
❑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 fit. ft.
❑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 DEscmt>rtoN color,karaocss,solUrock ruin size etc.)
0 ft• 69 f1• Dirt
4.Date Well(s)Completed: 3-8-23 well ID# 69 ft- 245 `t• Rock
5a.Well Location: ft. ft •;�, n^`vim 1
Paul Mesimer n�
Facility/Owner Name Facility ID#(if applicable) ft- ft. - L V L
Altavista Way, Lenoir NC 28645 ft. ft. .i,.�,.,..'; : :,i.,• :, v; 3 la'r;i
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:
(ifwell field,one lat/long is sufficient) 22.C •[cation:
35' 99.747' N 81' 58.933' W - 3/24/2023
6.Is(are)the well(s): [RPermanent or ❑Temporary Signature of Certified YMI 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.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 finut.
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: 245 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if elifferent(example-3@200'and 2@I00D
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing. (fL) 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: AI r 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
5
13a.Yield(gpm) Method of test: i r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018