GW1--02112_Well Construction - GW1_20240405

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 10 ft 345 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. 85 ft. 6.25 'in. SDR21 PVC
Company Name
1111 .-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. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑lndustrial/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 ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) e,.. ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solUrock type grain size eta)
0 fr. 80 ft• Dirt
4.Date Well(s)Completed: 3-8-2024 Well ID# 80 ft 345 ft Rock t
5a.Well Location: ft. ft. ' ".. 7.- "
Taryn Dillard&Garrett McDonald ft. ft. I "' `r L.., ,,;/
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR R 0 r 2024
1698 Hwy 268. Lenoir NC 28645 ft. ft.
ld},, Y�• 1 it ;-r ^g,>,..._
Physical Address,City,and Zip ft. ft. i DV:(`y=1 �'•°�+�N'4
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.Certification:
36.000.09' N 81 .538.44' w elez.4.ii,
3/19/2024
6.IS(are)the well(s): Permanent or ❑Temporary Signature of Certified Well ontractor ! 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 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 of the of this record has been provided to the welli 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: 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@100')
10 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fl•) 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: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 ovi r'100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018