GW1-2022-08794_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
60 ft. 1325 ft.
3254 A it I ft
NC Well Contractor Certification Number
15.'OUTER,CASING fof.multi cased wells'ORLINER if a"'►ieible
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 58 ft- 6.25 in. ISDR21 JPVC
3379`+2 IC',INNER' ASING ORrTUBING "eothefmit'closed-lo6
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2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. M in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: d7:=SCREEN .
FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Mutucipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) g, ft. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it• 20 it Grout Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
;19.'SAND/GRAVEL;P,ACK_if.a ticable
❑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;DRILLIlVGliOG attacti iidditionil$heets'if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size etc
0 it. 53 it Dirt
4.Date Well(s)Completed: 6-17-22 Well ID# 53 fL 325 fL Rock
5a.Well Location: ft ft
Charlotte Dog Club ft. ft. SEP 0 9
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. c m c nC :,% Una
1800 Amity Hill Rd, Cleveland, NC 27013 ft ft r­1,VQi-OG
Physical Address,City,and Zip ft. ft.
Rowan 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we0 field,one lat/long is sufficient) 22. cation:
35' 72.052' IX/ 4-1
N 080. 72. 215' W
8/24/2022
6.Is(are)the well(s): WPermanent or ❑Temporary Signa a of Certified Well 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 1!lNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100')
10.Static water level below top of casing: V 0 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r 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 Wm) 25 Method of test:Ai r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 Cup
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Form GW-1 i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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