GW1--07243_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Chris C Russell 14:wATERzoxEs '
We1lContractorName FROM TO DESCRIPTION
3254 A 80 ft 425 ff. 1
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. 55 ft. 6.25 in. SDR21 PVC
Company Name
1�25 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.
•17c SCREEN `_` ;
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. la.
OGeothermal(Heating/Cooling Supply) 1'IResidential Water Supply(single) ft ft In.
❑industrial/Commercial ❑Residential Water Supply(shared) ' 18:GROUT
❑Irrigation ❑Wells>100,000GPD 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 0 Groundwater Remediation Y9.SAND/GRAVEL PACK(if applicable).
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology 0 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. 51 ft. Dirt i
4.Date Well(s)Completed: 6-12-2023 Well ID# 51 ft. 425 ft Rock
ft. ft. •
t �-k,v'lk.:.r' 1 '`'„_
5a.Well Location:
Joseph Battista •Todd Triplett ft. ft NOV i,' S 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1388 High Valley Way, Lenoir NC 28645 ft. ft. In irrr,r.2 71 P' : Kt 0 i=i-
ft.
Physical Address,City,and Zip ft. L "' ""'�Caldwell s'2L REMARKS•.;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.C rtification:
35.87.114' N 81.66.562' W 10/24/2023
"Xd/..4.-) ) .;,..eLe_isee.
6.Is(are)the well(s): OPermanent or ❑Temporary Sr tore of Certified 11 Contractor Date
By signing this form,'hereby certij5.,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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#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 ntcassary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:425 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a�00'and 2@100')
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0.0 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use••+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NCa27699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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) 6 Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018