GW1--06319_Well Construction - GW1_20230927

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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 60 ft.. 505 ft. I
ft. ft. I,
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. 160 ft 6.25 in* SDR21 PVC
Company Name 2.Well Construction Permit#:W5 C58 16.INNER CASING OR TUBING(geothermal closed-loop)
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 ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft. ft. in'.
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft- Grout Poured
❑Monitoring ❑Reco very ft. ft.
Injection Well: '
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
['Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
['Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 155 ft. Dirt
4.Date Well(s)Completed: 8-22-23 Well ID# 155 ft• 505 ft• Rock
5a.Well Location: ft. ft. µ_ -. i 7:::!'").
Michael Messick ft. ft. , � 'I-. , �r` " "
Facility/Owner Name Facility ID#(if applicable) ft. ft. S E p 2 rt 7 023
2391 Dover Church Rd, Taylorsville NC 28681 ft ft. b
Physical Address,City,and Zip ft. ft lftia;+ram`n N I p'',� L Cx
Alexander 21.REMARKS �`t.t `!moo ,
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 ification: ,
35.917.98' N 81 .234.43' W 9/12/2023
6.Is(are)the well(s): llPermanent or DTemporary Signature of Certified 11 Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or nNo 15A NCAC 02C.0100 or I SA 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: 505 (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 2@100) 1
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (It) 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
13a.Yield(gpm) 3 Method of test:Air Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/2 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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