GW1--07252_Well Construction - GW1_20231108

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
TO DESCRIPTION
Well Contractor Name FRt ROM
3254 A 80 ft. 365 ft.
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 102 ft• 6.25 SDR21 PVC
Company Name 4 16.INNER CASING OR TUBING(geothermal closed-loop)
W
2.Well Construction Permit#: - -53 " 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) OResidential 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
❑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. 97 ft. Dirt
4.Date Well(s)Completed: 10-19-2023 Well ID# 97 ft• 365 ft• Rock '\ ..-v.,• w s) ,j-
ft. ft. NOV 0 S 2023
Sa.Well Location:
Steven Watts Sedgewick Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ^;.
480 Quail Hollow Lane Taylorsville NC 2681 ft. ft.
Physical Address,C'it.,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.Certification:
35.963.587' n 81 .212.331' w 11/7/2023
�K ) actor
6.Is(are)the well(s): OPermanent or ❑Temporary tore o ertt ed We ,.actor 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 DNo 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#2l 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' Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different((tample-3@200•and 1@I00')
80
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 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.)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 0 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018