GW1--04670_Well Construction - GW1_20240809

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
250 ft• 245 ft.
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Iicable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 58 ft• 6.25 in• SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1088 FROM TO DIAMETER THICKNESS 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. in•
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/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 OSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft• ft•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I DESCRIPTION(color,hardness,soil/rock type,grain size•etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 53 ft. Dirt
4.Date Well(s)Completed: 5-24-2024 Well iD# 53 ft. 640 ft. Rock
5a.Well Location: It. ft.
Billie & Scott Underbrink First In Flight Const. �+`./1
Facility/Owner Name Facility ID#(if applicable) ft. ft. A U G 0 9 20?4
2360 Timberview Drive, Lenoir NC 28645 ft. ft.
Physical Address,City,and Zip ft. ft. n.,,,, t -
Caldwell 21.REMARKS
County Parcel Identification No.(PIN) Self-Certification
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.024.11' N 81.485.76' W (117,44.: �G4.C.c1(
6/17/2024
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
I
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 itNo iSA 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 surfacer (R') 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)
250 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R-) 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 CUP
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018