GW1--01269_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES (-':_'.': -
FROM TO DESCRIPTION
Well Contractor Name
3254 A 200 ft. 905 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. 75 ft. 6.25 ; SDR21 PVC
Company Name 2023-27839 •: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. I in.
3.Well Use(check well use): ft' ft. m
'`17.SCREEN . .,.. :."
Water Supply Well: FROM TO DIAMETER' SLOT SIZE _ THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) IJResidential 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 it• 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) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock type,grain size etc.)0
0 ft. 70 ft. 'Dh1
4.Date Well(s)Completed: 2-9-2024 Well ID# 70 ft. 905 ft• Rock
5a.Well Location: ft ft. T+ _
f
Glenn King ft. ft. ' lac_"/" .E..
Facility/Owner Name Facility ID ft. ft.
#(if applicable) F�p 2 � ����
1415 Starbuck Dr, Statesville NC 28625 ft. ft. D
Physical Address,City,and Zip ft. ft. ' 41i`flri'itt�jt:'•;•1 pr3M
lredell :21.REMAR1CS DWQ.j + , ' .
1
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:
35'993.58' N 80'995.14' W &1441)- 2/12/2024
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certifie4,0_4,Contractor Date
By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!'JNo 1SA NCAC 02C.0100 or 15,4 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: 905 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(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: 200 (ft) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" r
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) 1 Pint Method of test:• Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTC Amount:2 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018