GW1--01266_Well Construction - GW1_20240229

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES - '-*._I-:. - '
, FROM TO DESCRIPTION
Well Contractor Name -
3254 A 80 ft. 325 ft.
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. 87 ft. 6.25 i ,in• S DR21 PVC
Company Name
4717-30-9651 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.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREN
Water Supply Well: FROM TO DIAMETER` SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/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. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19.SAND/GRAVEL PACK(if applicable) ''
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG(attach additional sheets if necessary)'-'=';: . '
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 82 ft Dirt
4.Date Well(s)Completed: 01-03-2024 Well ID# 82 ft, 325 ft. Rock
5a.Well Location: ft. ft. i' r� ^
Ryan Douglas ft. ft. �-�,L t%' f)
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEB
919 Midway Drive, Stony Point NC 28625 ft. ft. 202
Physical Address,City,and Zip ft ft. • Il FVftaijen Pr x:04 02 unic
,21.REMARKS :. Oral t.3E3' -.:' -
Iredell �
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, rtification:
35.855.53' N 80.977.10' w 1/11/2024
6.Is(are)the well(s): IJPermanent or OTemporary Signs of Certified Well C tractor Date
By signing this form,I hereby certit,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 15A 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 oldie 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: 325 (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)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (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,NC27699-1636
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 producin g over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 15 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018