GW1--03791_Well Construction - GW1_20230602

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 40 ft. 545 ft-
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 193 ft- 16.25 In SDR21 JPvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 988 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
❑hri 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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. fL
❑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 DESCRIPTION(color,hardness,soittrock type rain size,etc.)
0 ft. 88 ft. Dirt
4.Date Well(s)Completed: 4-1 3-23 Well ID# 88 ff 545 ff Rock
ft. ft.
5a.Well Location: O
ft. ft. 1 `t
Craig & Michelle Burgus
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4 vl••
Millers Creek Rd, Lenoir, NC 28645 ft. ft. u"ram'
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:
(if well field,one Iat/long is sufficient) 22.Certification:
35' 965.51' N 081' 486.12' W - 5/17/2023
6.Is(are)the well(s): Permanent or ❑Temporary ngnature of Certified Well ontmctor 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
Ifthis is a repair,fill out known well construction information and explain the nature of the 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: 545 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di,jjerent(example-3Q200'and 1 ca 100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (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 Welts:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-163G
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
13a.Yield(gpm) 6 Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018