GW1--00279_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor car FROM TO DESCRIPTION
3254 A 80 ft• 445 ft.
It. 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. ft' 6.25 i"' SDR21 PVC
Company Name
1 067 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.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) l Residential 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.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test ❑Stornwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
0 ff• 129 ft. Dirt
4.Date Well(s)Completed: 12-7-2023 Well ID# 129 ft. 445 ft. Rock
ft. ft.
5a.Well Location:
Tom Prichard Moss Marlow ft ( ,„ g ,LL :
Facility/Owner Name Facility 1D#(if applicable) ft• ft
6177 Painted Ridge Trail, Lenoir NC 28645
ft. ft. .faN 05 1024 J
Physical Address,City,and Zip ft. ft. Ntts:ree,g4re•1 ,l•,v-
Caldwell 21.REMARKS Dbl/tar?n:: Utz
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. rtlflcation:
35.882.31' N 81 .114.07' W 12/8/2023
6.Is(are)the well(s): CIPermanent or ❑Temporary Signature of Certified Well Contractor 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 eiNo 15A NCAC 02C.0100 or 1SA 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 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:445 (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)
80 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (B•) 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.)
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)V
G Method of test: Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 1/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018