GW1--03407_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD (G W-l) For Internal Use Only: I
1.Well Contractor Information:
Chris C Russell 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
60 ft. 185 ft-
3254 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 80 ft. 6.25 in. SDR21 PVC
Company Name
W ELL-240103-02 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) elResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
['Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ['Salinity Battier 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)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 75 ft. Dirt
4.Date Well(s)Completed: 5-1-24 Well ID# 75 ft. 185 ft. Rock
ft. ft.
5a.Well Location: _
Andrew Auton & Faith Isenhour ft. ft.
Facility Ovi net Name Facility lD#(if applicable) ft. ft.
5340 Coons Drive, Conover NC 28613 ft. ft. r i c_
ft. ft. 54\E`,L.t LL.r
Physical Addree,.City,and Zip qg.}�
Catawba 21.REMARKS JUN l 0
aunty Parcel Identification No.(PiN) knier sSgtD p"Ccswin/WE
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 00/tOil14
(if well field,one Iat/long is sufficient) 22.Certification:
35.781.45' N 81.214.28' W 5/10/2024
6.Is(are)the well(s): Permanent or ['Temporary Signs of Certified Well nttactor 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 iSA NCAC 02C.0100 or 1 SA 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: 185 (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@100)
60 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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
40 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTC Amount: 1/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018