GW1--02823_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 I
Well Contractor Name FROM TO DESCRIPTION
3254 A 75 ft. 385 ft I ,
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
0 ft. 95 ft. 6.25 I in. SDR21 PVC
Company Name
1112 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. v in.
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FFRR SCREE OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) LtResidential 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 ❑Recovery ft. ft.
Injection Well:
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. 1
❑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,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 90 ft. Dirt
4.Date Well(s)Completed: 1-1 5-2024 Well ID# 90 ft. 385 ft. Rock
Sa.Well Location: ft. ft. s R •- :.�i"":�
Andrew & Jill Kirby ft. ft. ! \' `-�L"'' '- -��
Facility/Owner Name Facility ID#(if applicable) ft. ft "Ay All 0 c ZGZ4
5789 Charlie Little Rd, Granite Falls NC 28630 ft. ft. -.9?.,`t Jo.
Physical Address,City,and Zip ft. ft. I trA37;r ``��.•aOG
I vfikxr is
Caldwell 2L 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.Certification:
38.834.21' N 81 .386.19' w zL 4/2/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well ontractor Date
By signing this fonn,I hereby certifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or ISA 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. 1
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: 385 (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)
10.Static water level below top of casing: 75 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I I
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 d
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
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 60 Method of test:Air
13b.Disinfection type: HTC Amount: 1 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018