GW1--02116_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
80 ft. 425 ft.
3254 A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased.welts)OR LINER(if ap licable) "
Russell Well Drilling, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
0 ft. 148 ft• 6.25 i 'n• SDR21 PVC
Company Name -
1120 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 OMunicipal/Public ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) 11Residential 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 it Grout ' Poured
❑Monitoring []Recovery ft. ft.
Injection Well: - •
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
'1.9.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑StormwaterDrainage ft ft t
❑Experimental Technology ❑Subsidence Control ft. ft. .
❑Geothermal(Closed Loop) OTracer ,20.DRILLING LOG(attach additional sheets if necessary).
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft' 143 ft• Dirt '
4.Date Well(s)Completed: 2-14-2024 Well ID# 143 ft. 425 ft• Rock
ft. ft.
5a.Well Location: . " ^..
Steve & Debra Brockett ft. ft. , ' Le l-i' � '.,o')
Facility/Owner Name Facility ID#(if applicable) f ft.t. 4 PR C 5 2024
3195 Taylorsville Rd, Lenoir NC 28645
ft. ft. itii'c,Tr.e..n?rn• •
Physical Address,City,and Zip •° %19, U13/
Caldwell -21.REMARKS . -` '. 1.'te1
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.C tification: '
35.915.01' N 81 .358.83' wdh,,,:.) 3/5/2024
6.Is(are)the well(s): OPermanent or Temporary Signature of Certified Well
Co trot 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 ONo 15A 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 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:425 (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') 1
24a. For All Wells: Original form;to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
If water level is above casing,use"+" i,
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department t 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 27699-1611
13a.Yield(gpm) 6 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