GW1--02123_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 714 WATER ZONES 1 . • `. -
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 11. 545 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
Company Name •
0 ft 78 ft. 6.25 I in' SDR21 PVC
16.INNERCASING OR.TUBING(geothermal closed-loop).
2.Well Construction Permit#: '1�'V/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): ft. ft. in•
Water Supply Well: 17.SCREEN .„ -.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
llAgricultural OMunicipal/Public ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
0 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 0 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 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20:DRILLING LOG(attach additional sheets if necessary) • - -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 73 ff. Dirt
4.Date Well(s)Completed: 2-27-24 Well no 73 ft. 545 ft- Rock
5a.Well Location: ft. ft P r:,7-,,F---,,
Ricky W i ke ft. ft. " { %..P ii,,:,,t{ r::!I
Facility/Owner Name Facility ID#(if applicable) ft. ft Q PR
0
5 2O2
1131 Hopewell Ch Rd, Hiddenite NC 28636 ft. ft. Li,1.-::c.l Pf^^�
Physical Address,City,and Zip ft ft. CYI�`v'f` m •'F+' .�tir^�$S
Alexander 21.REMARKS 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22. rtitieation:
35.995.19' N 81 .05.449' w 3/4/2024
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6.Is(are)the well(s): (Permanent or ❑Temporary tore of Certified we►Contractor Date
By signing this form,I hereby certtty that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 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. j
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: 545 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is 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
13a.Yield(gpm)2 Method of test:Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
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13b.Disinfection type: HTC Amount: 1 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018