GW1--06321_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.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 645 ft, 120 ft• 1
ft. ft. 1 1
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. 32 ft. 6.25 i in. SDR21 PVC
Company Name
W 516 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.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) inesidential 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
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer 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)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 27 ft. Dirt
4.Date Well(s) 5-26-23 Completed: Well ID# 27 ft' 645 ft. Rock L.i! r
r-.. �,,r.=^7,. $,.,,,�, -�
5a.Well Location: ft. ft. 1",.°� w,. i
Thomas & Debra Miller . ft. ft. SEP 2 7 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
168 Heart Creek Lane, Stony Point NC 28678 ft. ft. 1fht. i iCII Pr.-,^ • `.:y.3 Ur3
C?'°
Physical Address,City,and Zip ft. , ft "�''
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.C tification:
35.906.83' N 81 .025.19' W 9/22/2023
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certified Well tractor Date
By signing this form,1 hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !No 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#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 ifdifferent(example-3@200'and 2@100')
24a. For All Wells: Original foim to Division of Water Resources (DWR),
10.Static water level below top of casing: 120 (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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
T
13b.Disinfection type: HTC I Amount: 1 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018