GW1-2022-07088_Well Construction - GW1_20220801

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Well Drilling, Inc. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 80 ft 225 ft.
3254 A ft. tt•
NC Well Contractor Certification Number
15.OUTER CASING(far multi-cased wells'OR`LINER if a Ilcable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 85 ft- 6.25 ' in- SDR21 JPVC
Company Name
RB P R-02-2022-39984 16.INNER CASING OR TUBING eothet•mal closed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIG County,State.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) CRResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ILrr 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
39)SAND/GRAVEL-PACK'(ifapplicable
❑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 necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
0 ft' 80 ft. Dirt
4.Date Well(s)Completed: 6-14-2022 Well ID# 80 ft 225 ft- Rock
t
5a.Well Location: ft ft
Mark Dellinger D&E Properties ft ft. AUG t 1
Facility/Owner Name Facility ID#(if applicable) ft. It.
Unk
3470 Storybrook Ln, Sherrills Ford, NC 28673 ft ft.
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 laUlong is sufficient) 22.Certification:
35'59.954' N 081 .04.856' W 7/13/2022
6.Is(are)the well(s): ®Permanent or ❑Temporary Signature of Certifie Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1!lNo 15A NCAC 02C.0100 or 15A NCAC 01C.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#21 remarks section or on the back afthis 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: 225 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di,/ferent(example-3@200'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 80 (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NCi27699-1636
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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method
25 of test
Air Drilled Permit Program,1611 MSC,Ralei gh,NC 27699-1611
:
13b.Disinfection type: H 1uT H Amount: 1/2 cup
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018