GW1--04622_Well Construction - GW1_20240809

1.VS CrU l.uulracwa lanVlmauwu. I .
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 ft. 405 ft-
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 191 ft. 6.25 in. SDR21 PVC
Company Name
1052 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
t7.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/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 ft. 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 ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 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)
o ft. 186 ft• Dirt
4.Date Well(s)Completed: 5-19-2024 sell ID# 186 ft• 465 ft. Rock
ft. ft.
5a.Well Location: - -
Kevin &Catherine Markey John Sprinkle ft ft , ;-`.,•i-.! `,I . �
Facility/Owner Name Facility ID#(if applicable) ft ft
5981 Box Turtle Rd, Lenoir NC 28645 ft. ft. Atli., 4 9 2024
Physical Address,City,and Zip ft. ft. ll,;:.l:T ..t t1 ,t-rr -.t iJ4.1
Caldwell 21.REMARKS Ds1C',C4
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. erti ication:
35.971 .61' , 81 .692.76' W 7/18/2024
6.Is(are)the well(s): !Permanent or ❑Temporary ttue of Certified We 1 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 !No 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.
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: 405 (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a200'and 2@100')
G 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use'•+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.25 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Well 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
5
13a.Yield(gpm) 1 Method of test: Air
13b.Disinfection type: HTC Amount: 1 1/3 cup
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018