GW1--06357_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information: ,
Chris C Russell 14.WATER ZONES
FROM. TO DESCRIPTION
Well Contractor Name 60 ft. 500 ft
3254 A ft. ft. I j
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' 110 ft' 6.25 SDR21 PVC
Company Name
W P 1062 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. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR SCREENTO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMEN1IMETHOD&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)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft.
❑Experimental Technology 0 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,soiVrock type,grain size,etc.)
0 ft, 105 ft. Dirt
4.Date Well(s)Completed: 9-15*2023 Well ID# 105 ft• 500 ft• Rock
5a.Well Location: ft. ft.
William & Laurie Schoonover John Sprinkle ft. ft. _.., '. -'°
Facility/Owner Name Facility ID#(if applicable) ft. ft. : _;:..(���t. i,V .-•-- -''
6130 Painted Ridged Tr, Lenoir NC 28645 ft. ft. 1DTI
ft. ft. .
SEP
Physical Address,City,and Zipra
Caldwell 21.REMARKS r�r• "'''•'""1J
llli'1s"" ,%;:-;c =
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. 335.45' N 82.733.67' W 9/27/2023
6.Is(are)the well(s): ❑Permanent or ❑Temporary attire of Certified well ontractor 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 nNo 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 I 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: 500 (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')
10.Static water level below top of casing: 60 (ft") 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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) 7 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 3/4 cup
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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