GW1-2022-08774_Well Construction - GW1_20220909

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
3254 A 60 IL 178
ft. M f
NC Well Contractor Certification Number
iS:OUTER CASING for multi cased wells!OR LINER if a'"7icable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 138 ft 6.25 j In SDR21 JPVC
Company Name
WELL-02-2022-165919 I&INNER.CASINGSORTUBING cotheriniIcl6sedbb u
2.Well Construction Permit#: FROM To DIAMETER THICICKEsS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. ! in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17JSCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [AResidential Water Supply(single) fI. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fa 20 fr. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
SANDIGRAVEL.PACK(ifa' liteble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft M
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.:DRILLINGLOG attacti"additionahsbeets if=necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,naraae soil/ruckrain size etc.
0 ft. 33 ft. Dirt
4.Date Well(s)Completed: 6-28-22 Well ID# 33 ft. 178 ft. Rock
fL ft ;� F 1'
5a.Well Location: ram„ ,e s
Bondilyn Coley fL ft. _
Facility/Owner Name Facility ID#(if applicable) fL ft. -
6296 Ruffin Lane, Conover, NC 28613 ft. ft ��^- Urd
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:
(ifwell field,one lat/long is sufficient) 22.C •'cation:
35' 80.671' N 081' 22.446' W
8/24/2022
6.Is(are)the well(s): JlPermanent or ❑Temporary 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: ❑Yes or 1!lNo 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 native ofthe ofthis 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-i 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: 178 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 a200'and 2@I00)
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iff Static water level below top of casing: (ft) Information Processing Unit,1617 iMSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy tI DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 producin¢over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,13a.Yield(gpm) 100 Method of test:AI r NC 27699-1611�
13b.Disinfection type: HTH Amount: 1/2 Cup i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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