GW1-2021-00999_Well Construction - GW1_20210419

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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
40 ft 225 ft•
3254 A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR_LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 55 ft1 6.25 in SDR21 I PVC
WELL-10-202-140725 1&INNER CASING ORTUBING eothermal 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): tt. ft. in.
Water Supply Well: 17.'SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) tAiGROUT
_ 1M at10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 ft Grout Poured
Monitoring DRecovery
injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK tfa licable
Aquifer Storage and Recovery E)Salmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology f3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRII.LING;LOG,attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock a rain size etc.
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) 0 ft' 50 ft. Dirt
4.Date Well(s)Completed: 3-11-2021 weu ID# 50 it 225 Rock
5a.Well Location:
Americas Home Place AHP
ft. ft.
Facility/Owner Name Facility ID#(if applicable) w
8300 Drena Dr. Sherrills Ford, NC 28673Q ON
Physical Address,City,and Zip ft. ft.
21.REMARKS
Catawba n
{r1T1 C � r.ifJ
County Parcel Identification No.(PIN) "3 t� t
kj y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ifieation:
35' 34.306' N 080' 58.641' W ,
3-18-2011
6.Is(are)the well(s)OZ,Permanent or Temporary Signature of Certified Contractor Date
By signing this form,I herebv cerlifv Mal the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
if this is a repair,fill out known well cones-uction information and explain the nature o/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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJjerent(example-3(tr 200'and 2L100') construction to the following:
10.Static water level below top of casing:40 (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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 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: 2/3 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