GW1--03795_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 20 ft. 500 ft-
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINE Rif a livable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 29 ft. 6.25 in• ISDR21 1PVC
41►I C�p 16.INNER CASING OR TUBING(eothermal closed-loop)
2.Well Construction Permit#. V V J 8 FROM TO DIAMETER TmcKNEss MATERIAL
List all applicable well construction permits ii.e.UIC,Comty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. It. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mwricipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. 20 It- Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity BaCK m 19.SAND/GRAVEL PA if alivable
Barrier FROM I TO I bATERIAL 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 necessa )
❑Geothermal FROM TO DESCRIPTION(color,hardness,soil/rack c, in siu,etc.)(I-Ieating/Cooling Return) ❑Other(explain under#21 Remarks) ft' Dirt
4.Date Well(s)Completed: `�-24-23 Well ID# 0 ft. 25 25 ft- 500 ft- Rock
5a.Well Location: ft. ft. r`; .lL
Carol Moss Boyce Galliher ft. ft. Iq sl 9n l
Facifity/Owner Name Facility ID#(ifapplicable) et• ft
55 Sebastian Ct. Taylorsville NC 28681 ft. ft. INc,-m-"V.:s,I . M. -SX?dz,;a N
Physical Address,City,and Zip ft ft. "--
Alexander 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. 965.45 N 081. 099.57' W 5/12/2023
6.Is(are)the well(s): ©Permanent or ❑Temporary Signature ofCertified Well Contractor Date
Bysigning thisform,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MN0 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 921 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 I 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 INSTRUCTIONS9.Total well depth below land surface: 500 (ft)
For multiple wells list all depths if dierent(example-3�00'and 2@100') ( Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 20 (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+' ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
(i.e.auger,rota 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
g ry,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) Method of test:
2 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 2/3 cup
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018