GW1--01268_Well Construction - GW1_20240229

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
3254 A 40 ft, 345 ft-
ft. ft. I
NC Well Contractor Certification Number P 15.OUTER CASING(for multi-cased wells)OR LINER,(if ap licable) .
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 it 00 ft, 6.25 SDR21 PVC
Company Name .,16.INNER CASING OR TUBING(geothermal''closed-loop)._ -
2.Well Construction Permit#: 2023-32774 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) nResidential Water Supply(single) ft. ' ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8rGROUT.
❑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.
DAquifer Recharge 0 Groundwater Remediation
-19.'SAND/GRAVEL PACK(if
[Aquifer Storage and Recovery 0 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) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 95 ft. Dirt
4.Date Well(s)Completed: 2-5-2024 Well ID# 95 ft. 345 ft, Rock ,
5a.Well Location: ft. ft.
Matthew Link Sedgewick Homes ft. ft. .~-,.., _
L.5$ (,� v
Facility/Owner Name Facility ID#(if applicable) ft ft. t,/ � ii
406 Grant Rd, Statesville NC 28625 ft. ft. FEB 2 9 2024
Physical Address,City,and Zip ft. ft
Iredell ',21.-REMARKS. .. .Frr6rrlilf51;4rf4.4 pt;,.31
wriQr'3oG
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:
35.943.782' N 80.931 .585' W ), -)qt,j...r.,.s.L., 2/26/2024
6.Is(are)the well(s): nPermanent or ❑Temporary
Signature� d Well Contractor Date
By signing this form,I hereby certity that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 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 remark 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:345 (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@l00')
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
(ie.auger,rotary,cable,direct push,etc.) county environmental health department ent 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 m 4 Method of test:Air Drilled Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
(gP ) HTC Disinfection type: H I C Amount: 1 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018