GW1--06494_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 100 ft• 185 ft•
ft. ft.
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
Company Name 0 ft. 31 ft• 6.25 in. SDR21 PVC
W274072 16.INNER CASING OR TUBING(geothermal closed-loop) ,
2.Well Construction Permit#: 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. i°'
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural JMunicipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
*Industrial/Commercial DResidential Water Supply(shared) 18.GROUT .
*i Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Grout Poured
*Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
*Aquifer Recharge 'Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test ljStormwater Drainage ft. ft.
*Experimental Technology DSubsidence 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.)
®l Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft. 26 ft• Dirt
4.Date Well(s)Completed: 10/21/2024 Well ID# ft• 185 ft• Rock _
5a.Well Location: ft. ft. " n ',
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1:
Lee Scruggs ft. ft. "'
Facility/Owner Name Facility ID#(if applicable)
ft. ft. NOV t! - COL4
10990 Depot Rd, Woodleaf, NC 27094 ft. ft. In fc,; ",, '?,i^,f., t:_,..,
^4
Physical Address,City,and Zip ft. ft. L"r`"�'�'°'3
Rowan 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. rtification: '
35.789.24' N 80.569.03' �, _
• ,i�� 10/28/2024
6.Is(are)the well(s)JPermanent or Temporary S ure of Certified Well onuactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or DINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 85 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: ,
10.Static water level below top of casing: 00 _ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTC Amount: 1/3 cup completion of well construction t I the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
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