GW1--02822_Well Construction - GW1_20240506

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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
3254 A 30 ft• 125 ft
ft. ft. i
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 ft51 ft6 25 ' i"• SDR21 PVC
A -16c'INNER CASING OR•TUBING;(geothermal closed--loop)
2.Well Construction Permit#: 942 FROM TO DIAMETER THICKNESS 1 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. I in.
17.SCREEN :,,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) &Residential 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 ft Grout Poured
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) . .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer `20.DRILLING LOG(attach additional sheets if necessary)'
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 46 ft. Dirt
4.Date Well(s)Completed: 3-21-2024 Well ID# 46 ft. 125 ft. Rock
Sa.Well Location: ft. ft. i:$ .`--t ,•L_i. 1f 1.....
Michael Rane' Sedgewick Homes ft. ft. MAY 6 2024
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5589 Parkview Rd, Lenoir NC 28645 ft, ft. 1 ' •',.,.1 ,-`_,r -4 :g tM
lrr`,vi n.8 :
Physical Address,City,and Zip ft ft i 1.)t ��
Caldwell zr:REMARKS=
(
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Ce tification:
35. 951 .82' N 81 .368.09' W 3/29/2024
6.Is(are)the well(s): &Permanent or ❑Temporary Signature of Certified well ntractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &No 1SA NCAC 02C.0100 or 1SA 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: 125 (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 1@]00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (ft) Information Processing Unit,1617j'MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ff 1
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in,)
Program,1636 MSC,Raleigh,NCI+I27699-1636
12.Well construction method:Air Drilled I
24c,For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
(Le.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 27699-1611
13a.Yield(gpm)60 Method of test:Air 1
13b.Disinfection type: HTC Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018