GW1-2022-07092_Well Construction - GW1_20220801

k
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 ft. 205 ft.
it. ft. I
NC Well Contractor Certification Number 15 OUTER CASING for.multi cased wells OR LINER_if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 91 ft- 16.25 i in iSDR21 1PVC
Company Name
`:16'INNER CASING OR<TUBING eothermaf closed-loo '
2.Well Construction Permit#: WELL-06-2022-174451 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): ft. rL in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. p• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT k'
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. It.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVELPACK iLa" lica6le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets,if necessa
FROM TO DESCRIPTION color,hardness,soil/mck rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 86 ft. Dirt
4.Date Well(s)Completed: 7-12-2022 well ID# 86 ft 205 ft. Rock
5a.Well Location: IL ft. E tl /
Gregory Shell Jonathan Scronce ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. % AUG 0 _
RIZZ
1828 Houston Mill Rd, Conover, NC 28613 ft ft. Inkmation Proc2mine link
Physical Address,City,and Zip D%VQ/BQQ
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. rtification:
35' 77.203' N 081' 20.238' w 7/20/2022
26:4�
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified V&I 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.0200 Well Construction Standards and that a copy
If this 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 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: 205 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft.) Information Processing Unit,1617IMSC,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,NC 27699-1636
12.Well construction method: Air.Drilled I ,
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) 10 u u Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/2 cup
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018