GW1-2022-03818_Well Construction - GW1_20220404

t
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
3254A 60 ft. 445 ft- y
ft. ft !
NC Well Contractor Certification Number 15.OUTER CASING(for malti-cased'wells ORLINER if a" ticable
Russell Well Drilling, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
0 ft- 51 ft- 6.25 , '° SDR21 PVC
Company Name
WELL-10-2021-159383 16:INNER'CASING ORTUBING` eothermalclosed-too -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC Coun)4 State,Variance,etc.) ft. ft. in.
i
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.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. It.
❑lndustrial/Commercial ❑Residential Water Supply(shared) is.GROUT::
❑lni ation ❑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 Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessar)'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soilfrock type rain size,etc.)
0 ft. 46 ft Dirt
4.Date Well(s)Completed: 3-1 O-ZO22 well 1D# 46 ft- 445 ft- Rock
5a.Well Location: ft. ft. r-9 ti3
Marcel Toulouse ft. t` F
Facility/Owner Name Facility ID#(ifapplicable) ft. ft 2�2�
5316 Herman Rd, Claremont, NC 28610 ft. et.
Physical Address,City,and Zip ft. ft
Catawba 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.Certification:
35'78.227' N 081' 14.592' W 3/28/2022
6.Is(are)the well(s): WIPermanent or ❑Temporary St nature ofCertified ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe 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 pageito 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: 445 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iit dierent(example-3@200'and 2@100D
10.Static water level below top of casing: 60 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit, MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use'•+'• j
11.Borehole diameter: 6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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 depar cat of the county where installed
i
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 6 Method of test:Air Permit Program,1611 MSC,Raleigli,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
f