GW1--00289_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 50 f• 605 f=
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap likable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 45 ft. 6.25 SDR21 PVC
Company Name W 16.INNER CASING OR TUBING(geothermal closed loop)
Z.Well Construction Permit#: 555 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): It. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. g• in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f=• 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.)
o ft' 40 ft. Dirt
4.Date Well(s)Completed: 11-9-2023 well ID# 40 f=• 605 n• Rock
5a.Well Location: ft. rt. `;
Austin Williams ft. ft. AA�i EO
Facility/Owner Name Facility ID#(if applicable) ft. ft. J 4 I V 0 5 2024
1532 Chapman Mill Rd, Taylorsville NC 28681 ft
' It. If nrar,A:ien pr ,.
Physical Address,City,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:
35.948.30' N 81 .260.00' W �� 12i22/2023
6.Is(are)the well(s): OPermanent 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 allo 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 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: 605 (B•) 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: 50
(ft-) 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: A I r 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) 5 Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018