GW1--06458_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell .'14t WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 ft 165 ft. I 1
ft. ft. I I
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. 27 ft. 6.25 ;, • in. SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: 592 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
_ ❑Agricultural ❑Municipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15: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 Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. i
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)•
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
El Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 it 22 ft Dirt
4.Date Well(s)Completed: 9-13-2024 Well ID# 22 ft• 165 ft Rock
5a.Well Location: ft. ft. >. :
._: i 7
Joseph Briar Cothren ft. ft. " 4.. ' '..,s ' �''J
Facility/Owner Name Facility ID#(if applicable) ft. ft. NO V
379 Shook ValleyCt., Taylorsville NC 28681 ��`¢
Y ft. et. .. ,
Physical Address,City,and Zip ft. ft. ]rf 1 �i.,F t_--T..A ,'d ( S•'t
Alexander 21.REMARKS' y
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:
35.906.59' N 81 .177.12' W :;(� 10/4/2024
6.Is(are)the well(s): I lPermanent or ❑Temporary azure of Certified Il Contractor Date
By signing this form,I hereby certlfr that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 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 surface: 165 (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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (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)
,1 Program,1636 MSC,Raleigh,NCL27699-1636
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: 1/3 cup
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018