GW1--06318_Well Construction - GW1_20230927

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I fI
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft. 165 fit•
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. 81 ft- 6.25 : SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:W542 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in,,
❑lndustrial/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
❑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 soil/rock type grain size,etc.)
0 ft. 76 ft- Dirt '
4.Date Well(s)Completed: 4-4-2023 Well ID# 76 ft- 165 ft Rock ', _
5a.Well Location: ft. fit ,:t 1.,- V - _.;
Michael Citino ft. ft. (� j
Facility/Owner Name Facility ID#(if applicable) ft. ft. i SEr�j 2 7 2023
78 Jermyn Lane, Taylorsville NC 28681 ft. ft. ,r c;. : =::,P,,,,, d : I
Physical Address,City,and Zip ft. ft. Ll'Vr..,Wit-U
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:
35.703.89' N 81.165.01' W •
8/1/2023
e--4,,eJ6.Is(are)the well(s): I.1Permanent or ❑Temporary SignatuCertified Welt n[rector 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 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: 165 (fit) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiflbrent(example-3(41200'and 2@100')
60
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(TUC)
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 00 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1/3 cup
,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018