GW1--02789_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Chris C Russell '14.WATER ZONES .
F .� -��,,,, \t f�, TO DESCRIPTION
Well Contractor Name '!
m�`� FROM
40 B• 165 ft• 1 I
3254 A MAY 0 i 20Z4 ft. ft. 1
NC Well Contractor Certification Number ..15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) =
Russell Well Drilling, InGto,: �c c'+r.''•'o,;.'y (jr, FROM TO DIAMETER THICKNESS MATERIAL
U VI;4.,.;Duu 0 ft. 30 ft. 6.25 ; ,in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
•2.Well Construction Permit#: 1040 W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN -.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural L'1Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential 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 It 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 0 Subsidence Control ft. ft.
(ClosedLoop) DRILLING LOG(attach additional sheets if necessary)".- , ...
❑Geothermal ❑Tracer 20. ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc)
0 fr. 75 ft. Dirt
4.Date Well(s)Completed:4-24-2024 Well ID# _ 75 ft. 165 it Rock
5a.Well Location: ft. ft.
William Church Sure Foundation Baptist Church ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hwy 421 Wilkesboro NC 28697 ft, ft.
Physical Address,City,and Zip ft. ft.
Wilkesboro 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,C r' cation:
36.190.85' N 81.412.33' w ''/ •
/ _ 4/30/2024
6.Is(are)the well(s): 8Permanent or OTemporary Signature of Certified Well onnactor; Date
By signing this form,'hereby certify 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 ivell 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 pate 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
r,
9.Total well depth below land surface: (IL) 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 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft') Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11. I I
Borehole diameter:6.25 (�) 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
(ie.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)40 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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