GW1-2021-00997_Well Construction - GW1_20210419

PrntTorm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name
50 f`• 345 ft•
3254A
ft. ft.
NC Well Contractor Certification Number 15.`OUTER CASING for multi-casedwells-0R'LINER if a lieable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 60 ft- 6.25 in SDR21 PVC
Company Name
WELL-08-2020-137299 i16.>rrrvERcnsnvGORTusnvG eothermarclosea-Ina
2.Well Construction Permit#: FROM TO DUMETER 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 17.SCREEN
PP Y Well: FROM TO DIAMETER ' SLOT SIZE TRTCKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/commercial Residential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• Grout Poured
Monitoring E3Recovery
Injection Well:
Aquifcr Recharge E)Groundwater Remcdiation
]9.SAND/GRAVEL`PAC K(ifa licablc
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional;sheets if necessary)
FROM TO DESCRTPTTON color hardness soll/rock rain sirs eta
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks 0 ft' 55 ft' D I rt
4.Date Well(s)Completed:2-25-2021 Well ID# 55 ft• 345 1- Rock
ft. ft.
5a.Well Location:
Moser Sedgewick Homes tt. f• _- � -�
Facility/Owner Name Facility ID#(if applicable)
29th St NE, Hickory, NC 28601
Physical Address,City,and Zip ft. ft.
Catawba .21.REMARKS sill
�� nrsar.: r.-
iy-7
County Parcel Identification No.(PIN) t' �f.Y10i1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertifieation: D
35'47.466' N 081' 16.136' W
3-8-2021
6.Is(are)the well(s)oPermanent or OTemporary St ture of Certified We Contractor Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EJNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy oJ7his 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:
A.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: SUBMITTAL INSTRUCTIONS
9.Total:well depth below land surface: 345 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welLv list all depths it-different(example-3L200'and 2L100') construction to the following:
10.Static water level below top of casing: 50 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6.25 (in•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air above, also submit one copy of this fond within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply&Iniection 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: HTH Amount: 1 cup completion of well construction to 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