GW1--04957_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 100 ft• 645 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. 72 ft. 6.25 in• SDR21 PVC
Company Name
1023 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.U/C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17. N
Water Supply Well: FROMREE
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) itlResidential 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 ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence 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 soil/rock type grain size,ere.)
0 ft. 67 ft. Dirt
4.Date Well(s)Completed: 6-15-2023 Well ID# 67 ft• 645 ft. Rock
5a.Well Location: ft. ft. j^: r'l al...
Levesque Family Trust Moss Marlow ft. ` ft. I `'`"'LI L.:( "J I.
Facility/Owner Name Facility ID#(if applicable) ft. ft. A I llI(ll' 0 7 ?O c 3
2089 Hitching Post Lenoir NC 28645 ft. ft.
iti*,,.4��. 1ti., irr.,-,.
ft. ft. dh^1 t h i:::0 Ur;s
Physical Address,City,and Ziprt.•. ;.,,-.17
Caldwell 1 ,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,Certif.ation•
35.965.51' N 81 .456.12' w �'%� ,.) e 7/27/2023
of Certified ell CI Date
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature rt
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or inNo 1SA 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 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: 645 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.)
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1/4 Method of test:Air
13b.Disinfection type: HTC Amount: 2 1/3 Cup i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018