GW1--05250_Well Construction - GW1_20240903

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 60 ft. 225 It.
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' 34 ft. 6.25 in- SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: n/a 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
lAgricultural ❑Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. is
❑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
OMonitoring ❑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.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 fr. 29 ft. Dirt
4.Date Well(s)Completed: 7-27-2024 Well ID# 29 ft• 225 ft• Rock
ft. ft.
5a.Well Location:
Bud Fox Fox Poultry ft. ft.
Facility/Owner Nalne Facility lD#(if applicable) ft, ft.
Lee Matheson Rd, Taylorsville NC 28681 ft. ft. .
Physical Address,City,and Zip It. ft.
Alexander 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. tit1cation•
35.902.08' N 81.138.15' W
-z.�. 0 8/5/2024
6.Is(are)the well(s): I lPermanent or ❑Temporary store of Certified We Contactor 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 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.
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: 225 (fL)
For multiple wells list all depths ifdii different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (IL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
If water level is above casing,use"+"
11.Borehole diameter 6.25 (in.) 24b. For Inlection 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
13a.Yield(gpm) 1 00 Method of test Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTC Amount: 1/2 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018