GW1--04955_Well Construction - GW1_20230807

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. 345 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 115 ft. 6.25 in. SDR21 PVC
Company Name
0 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 81 6 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.
17.Water Supply Well: FRO
SMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential 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 ft. 20 ft. 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
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 1 10 ft' Dirt
6-5-23 FF fl ► €
4.Date Well(s)Completed: Well ID# 110 ft. 345 ft. Rock `'ti i.,.-r,L._i Ol _r
5a.WellLocation: ft. ft. AUG 0 7 2023
Ryan Arentz ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ItifC, _i/C U Pr.^•,_ry 4;,.iQ Llii(
6080 Collette Ridge Circle, Lenoir NC 28645 ft. ft. DV+ 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:
(if well field,one lat/long is sufficient) 22.C tification:
35. 921 .73' N 081 .642.25' w 6/12/2023
6.Is(are)the well(s): OPermanent or ❑Temporary
Signature ofCe d Well C tracto`r 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 ISA NCAC 02C.0100 or ISA 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 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: 345 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@,200'and 1@100')
80 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 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) 1 0 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8