GW1--02161_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell '14.WATER ZONES t',I' ',:,.. . , , .
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft• 325 ft. 1
ft. ft.
NC Well Contractor Certification Number ;15.OUTER CASING(for multi-cased wells)OR LINER(if an licable) -
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 92 ft. 6.25 i. ; in. SDR21 PVC
Company Name
0560 P-2024-4646 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.) H. ft. i • 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 lResidential Water Supply(single) ft. ft. in.
❑Industrial/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 ❑Reco very __ 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. I'
❑Experimental Technology 0 Subsidence Control ft. ft. I.
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional sheets if necessary); "
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 87 ft. Dirt
4.Date Well(s)Completed: 03-12-2024 Well ID# 87 ft• 325 ft• Rock 1.
5a.Well Location: ft. ft i.,-t. n R_ .•`i d,
John Andrew McCormick ft. ft. i
Facility/Owner Name Facility ID#(if applicable) ft. ft. ' APR :�yy I' V i C 024
341 Moose Club Rd, Taylorsville NC 28681 ft. ft. mtcr I r Pr:_^.sae r c t
se
Physical Address,City,and Zip ft. ft. DMZ''30 G
Iredell .21:.REMARK5'
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: ,
35.736.94' N 80.884.49' W 3/25/2024
6.Is(are)the well(s): ClPermanent or ❑Temporary iarose of Certified Wel Contractor 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 lNo 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: 325 (ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00)
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"+" '
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
(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 lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 0 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018
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