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HomeMy WebLinkAboutGW1--03380_Well Construction - GW1_20240610 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 80 ft 565 It. 3254 A ft. ft. NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if ap licable) Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL 0 ft• 45 ft. 6.25 in. SDR21 PVC Company Name 0625W 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS ltt 11:RIAL 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 ❑Agricultural OMunicipal/Public ft. ft. in. ❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) ft. ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAI. EMPLACEMENT METHOD th AMOUNT Non-Water Supply Well: 0 ft. 20 rt. 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 OSubsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) 0 ft. 40 ft. Dirt 04-26-2024 40 rt 565 ft. Rock 4.Date Well(s)Completed: Well ID# t^ r 5a.Well Location: ft. ft. '-`r-1 1 f`L) Bright Son Properties Ashley Morgan ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N 1 0 2424 Deer Run West, Purlear NC 28665 ft. ft. yrkisintkiten ilgmempirig Uutil Physical Address,(it...ind uip ft. ft. DWCti 2v1 - Iredell 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.Certification: 36.211.33' N 81.382.88' N, Cottif#---) 7 5/22/2024 6.Is(are)the well(s): CIPermanent or ❑Temporary of Certified et onttactor 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 CINo 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: 565 ( ) 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') 80 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: (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 3 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) Method of test: 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