GW1--03799_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 50 ft 525 it.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR ca LINER if a lible
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 40 ft 6.25 in SDR21 PVC
Company Name 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.VIC,Co n(K State.Variance,etc) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 It. 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 TO MATERIAL 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 necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock typc rain size,etc.)
0 ft. 35 ft. Dirt
4.Date Wells Com leted: 4-20-23 Well ID# 35 rt• 525 ft- Rock .--�
5a.Well Location: ft. ft �, ��r iL..>i .�
Richard & Catherine Sufian ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. v
h H
rt. ft.
Russell Gap Rd, Taylorsville NC 28681
Physical Address,City,and Zip
rt.
Alexander 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Ce 'fication
36' 016.22' N 081'218.60' W 5/8/2023
6.Is(are)the well(s): 1'� ermanent or ❑Temporary Signature of Certified Wel-Peontractor 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 CINo 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 of the of this record has been provided to the well owner.
repair under#21 remarks section a•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: 525 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d(�erent(example-3@200'and 2@100')
10.Static water level below top of casing: 50 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water 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
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) 3 Method of test:Air 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