GW1--03798_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 80 ft- 405 ft.
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi-cased wells OR LINER it a 0cable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 196 It. 16.25 in SDR21 JPVC
W530 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. fL in•
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C9Residential 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 rt. 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
tL 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 fL 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 I TO DESCRIPTION(color,hardness,so;urock qpc,gnin size,etc.)
0 ft. 91 % Dirt
4.Date Well(s)Completed: 5-3-23 Well ID# 91 It. 405 1- Rock
Sa.Well Location: ft. ft.' ' 'd a •+'
. � ._Y
John Synder Boyce Galliher ft. ft. ` N�ti L L
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Landis Drive, Taylorsville NC 28681 ft. ft.
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.C tification:
35' 917.98' N 081'234.43' W 5/17/2023
6.Is(are)the well(s): ®Permanent or ❑Temporary Signtitore ofCcrtifrcd Well onttactor 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 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 GWA 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: 405 (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
f 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 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
1
13a.Yield(gpm) 5 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/4 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018