GW1--02114_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information: 1
Chris C Russell 14.WATERZONES ` i,:-
WellContractorName FROM TO DESCRIPTION
3254 A 80 ft. 405 ft I '
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' 100 ft. 6.25 ; lit SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) ;
2.Well Construction Permit#: n/a 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): It ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
l!lAgricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) ❑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 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 OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additionatsheets if necessary) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 95 ft. Dirt
4.Date Well(s)Completed: 2-15-2024 Well ID# 95 ft. 405 ft. Rock
5a.Well Location: ft. ft.
J. Gundalupe Cruz ft. -t. =_s t �a 4 '
.J - ...-F,
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4_
2910 Taylorsville Rd, Granite Falls, NC 28630 ft. ft. .APR 0 5 2024
Physical Address,City,and Zip ft ft. ln ,n.?::''17.!7/.....53aeu:(1a 1
Caldwell 21.REMARKS, , rsr r. ,.;)c .
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tiff lion:
35.971.61' N 81.486.52' w 3/5/2024
6.Is(are)the well(s): l!Permanent or Temporary Signature of Certified Well Contractor Date
❑
By signing this form,I hereby cert((y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0I00 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 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:405 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d�erent(example-3( 200'and 2@100')
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80 24a. For All Wells: Original form;to Division of Water Resources (DWR),
10.Static water level below top of casing: (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,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
Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1
13a.Yield(gpm) 10 Method of test:Air
13b.Disinfection type: HTC Amount: 1 1/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018