GW1--07916_Well Construction - GW1_20231208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Chris C Russell I'a.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
3254 A 70 ft• 365 ft. 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. 58 ft• 6.25 SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#. n/a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) H. 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.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/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 0 Groundwater Remediation a49.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. l'
❑Geothermal(Closed Loop) OTracer "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. 53 ft. Dirt
4.Date Well(s)Completed: 10-16-2023 Well ID# 53 ft• 365 ft. Rock
5a.Well Location: ft. ft
Jason Chester ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1205 French Belk Rd, Mt. Ulla, NC 28125 ft. ft. . s-,•',v. R,. .11 r'' .1 y)
Physical Address,City,and Zip ft. ft 95
Rowan re
:REMARKS-°a t of
County PaelldentificadonNo.(PIN) !fl '°-'`1'=m ,),-.�_^^°-
0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22, rtification:
35.665.50' N 80.764.80' w % 1) )e.A.42."6/.." 11/8/2023
6.Is(are)the well(s): !Permanent or ❑Temporary Signature of Certified Well Contractor) Date
Sy signing this form,I hereby cert(/that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !No 1 SA 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:
S.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:365 (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@I00)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:70 (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
(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
G
13a.Yield(gpm) 6 0 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