GW1-2021-07534_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD (GW-1) For Internat Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM TO DESCHIrflON
Well Contractor Name 60 ft 265 fr'
3254 A
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iieable
Russell Well Drilling, Inc. FROM TO DIAaIETRR THICKNESS MATERIAL
Company Name
0 ft• 80 ft 6.25 SDR21 I PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:WELL-05-2021-150586 FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fr. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft is
IndustriaUCornmercial Residential Water Supply(shared) 1S.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 Ir. 20 It. Grout Poured
Monitoring Recovery
Injection Well: ft ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/CRAVEL'PACK if applicable)
Aquifer Storage and Recovery OSaLinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 1ITracer 20 DRILLING LOG attach additional'sheets if necessary)
Geothermal eatin Cooling Return) ;Other(explain under#21 Remarks FROM TO DESCRTPTION color,hardness solt/rock type,gmin size ctc.
0 IL 75 ft- Dirt
4.Date Wetl(s)Completed: 5-24-21 Well ID# 75 fr. 265 fr' Rock
5a.Well Location: ft. ft. IN
D & E Properties ft. ft.
Facility/Owner Name Facility[D#(if applicable) ft. ft. 1
3452 Storybrook Ln, Sherrills Ford, NC 28673sing
1
Physical Address,City,and Zip ft. ft. 3ttOn Pro
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22. ertifieation:
35' 36.017' N 081' 02.859' w J °Z�
6.Is(are)the well(s)Or Permanent or OTemporary STg=f6e of Certified Well Contractor Date
By signing this form.1 hereby certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well comtruc•tion 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 265 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@7000'and 2@1001 construction to the following:
10.Static water level below top of casing: 60 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 Infection 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) 8 Method of test: Air 24c.For Water Supply&Infection 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