GW1--01311_Well Construction - GW1_20240229

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES;.' .-,;/',,, ,..-`: .• •r '
WeIlContractorName FROM TO DESCRIPTION
3254 A 100 ft' 285 ft. 1
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
Company Name 0 ft" 140 ft• 6.25 In. SDR21 PVC
1047 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in:
0 Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Grouts 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 0 Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 135 ft. Dirt
4.Date Well(s)Completed: 12-14-2023 Well ID# 135 ft 140 ft• Rock
5a.Well Location: ft• ft. i_ y,,'E 1t�
Christine Boccella Todd Tripplett ft. ft. °--0
Facility/Owner Name Facility ID#(if applicable) ft , ft F L tj 2 9 2024
2005 Shadow Ridge Trail, Lenoir NC 28645 ft• ft. nl�o Irarlie p,- ^
Physical Address,City,and Zip It. 1 ft. DWQ �+�
Caldwell 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. rtification:
35.971.61' N 81.486.52' W 2/5/2024
6.Is(are)the well(s): l IPermanent or ❑Temporary a of Certified I Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo 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 necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
285 r
9.Total well depth below land surface: (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@100')
10.Static water level below topof casing: 100 (ft•) 24a. For All Wells: Original form to Division of Water Resources (DWR),
a level Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If St above casing,use
11.Borehole diameter 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
(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
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 15 Method of test: Cups
Disinfection type: HTC Amount: 2 Cu ps
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018