GW1-2022-06548_Well Construction - GW1_20220511

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES -
WellContractorName FROM TO DESCRIPTION
3254 A 40 ft- 165
ft ft r j
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER if a "licable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 50 ft 6.25 '" SDR21 PVC
WELL-12-2021-162589 16.INNER CASING ORTUBINC eitherma]closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance.etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Pubtic ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I 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 necessa )'.
FROM TO DESCRIPTION color,hardness,soiVrock rain size,etc.
❑Geothermal(Heating/Cooling Return) OOther(explain under 921 Remarks) 0 ft. 45 ft. Dirt
4.Date Well(s)Completed: 3-28-2022 Well ID# 45 ft. 165 ft- Rock
5a.Well Location: ft ft
Brian Vachon Boyce Galliher ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
2926 Burnt Leaf Ln, Newton, NC 28658 ft. ft MiomA'iawn Procaiiailli Lw
Physical Address,City,and Zip
fL ft.
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ification:
36'36.592' N 081' 08.929' W 4/8/2022
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified well Contractor Date
By signing this form,/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.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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 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: 165 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifjerent(example-3@200'and 2@I00')
10.Static water level below top of casing:40 24a. For All Wells: Original form,to Division of Water Resources (DWR),
(ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+" I
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I :
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)20 Method of test: i r
13b.Disinfection type: HTH Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018