GW1-2022-08773_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATERZONES;-:
FROM TO DESCRIPTION
Well Contractor Name 60 1345 11. 1
3254 A f, ft.
NC Well Contractor Certification Number 15;,OUTER CASING(f6k.m1filti-divied.
wells)0 L��R ifs
%FL
Russell Well Drilling, Inc. FROM TO ft. DIAMETER T S MATERIAL
Company Name 0 ft 186 6.25 In. ISDR21 JPVC
.16.UINER CASINGOW ING.Uliotherknallildiii!4660)I�-�_::-:�-.: �--..
2.Well Construction Permit#: WELL-04-2022-1 69155 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): fL ft. in.
Water Supply Well: FROMSCREEN,TO DIAMETER I I SLOT SIZE THICKNESS MATERIAL
.
O.Agricultural DMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) RResidential Water Supply(single) -ft. ft. in.
01ndustrial/Commercial OResidential Water Supply(shared) . ... ....
48.:GR0IJT,�1:,:'�:I:
OIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
OMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation
49.SAND/GRAYEL, CK-lUa0pWable)i:z-
TA ( .
OAquifer Storage and Recovery OSatinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ClAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sol rack type�grain size,etc)
0 ft- 81 ft Dirt
4.Date Well(s)Completed: 7-12-22- Well lD# 81 IL 345 ft Rock
ft. ft.
5a.Well Location:
Clayton Homes ft. ft.
Facility/Owner Name Facility fD#(if applicable) IL IL SEP 0 9 2022
2885 Wilderness Trace, Claremont, NC 28610 ft. ft. Flfe-,-,ev-�g
Physical Address,City,and Zip ft. ft. DINQ13013
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.CeLlification:
35' 80.026' _N 81' 16.463' W 8/11/2022
6.Is(are)the well(s): RiPermanent or OTemporary Signature of Certified 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: oVes or ItNo 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y F ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 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@1 OOD
60 24a. For All Wells: Original form to Division of Water Resources (DVvR),
10.Static water level below top of casing:. (ft.) Information
Informa Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+" i I
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2*94636
12.Well construction method: Ai r D ri I I ed 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 depar i tritent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinti over 100,000 GPD:Copy to DWF,CCPCUA
13s.Yield(gpm) 10 Method of test:Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: HTH Amount: 1 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourciis Revised 6-6-2018