GW1--00282_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 Name FROM TO DESCRIPTION
] 60 ft. 265 ft.
3g�,5(4 A ft. ft.
NC Well Contractor Certification Number I 5.OUTER CASING(for multi-cued wells)OR LINER(if a licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 92 ft. 6.25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.We0 Construction Permit#: -5"Vic 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) l lResidential Water Supply(single) ft. ft. in.
❑lndustriallCommercial ❑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.
OGeothermal(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)
o ft. 87 ft. Dirt
4.Date Well(s)Completed: 11-21-2023 well ID# 87 ft 265 ft Rock _
5a.Well Location: ft. ft.
Alison Fairchild ft. ft.
Facility/Owner\amc Facility ID#(if applicable)
R. ft. i
VLD
5691 Low Country Rd, Lenoir NC 28645 ft. ft. TAN 0 5 2024
Physical Addrcss.Cie}.and lip ft. ft. Itti.-,rir,,."0 rz n ]
Caldwell 21.REMARKS DMfCTi 6G 9
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35.888.00' N 81 .660.90' wedi_D 12/5/2023
6.Is(are)the well(s): IJPermanent or OTemporary Sigoa atili
of lfied We
l 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 elNo 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'See Over'in Remarks Box).You may also attach additional pages if neaPasary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example-3 200'and 2@100')
10.Static water level below top of casing: 60 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level 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
(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) 25 Method of test: Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 2/3 Cup
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018