GW1-2021-01512_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATERZONES� '
FROM TO llFSCR1Y'I'ION
Well Contractor Name 60 ft' 245 ft'
3254 A
ft. tt.
NC Wc11 Contractor Certification Number 15.OUTER CASING for mutWcased'wells UR LINER if a' licitbte
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 70 ft• 6.25 'n• SDR21 PVC
Company Name 16.DINER CASING OR:TUBING, eothermat elose&loo"
2.Well Construction Permit#:WELL-05-2020-133052 FROM TO DIAMETER TIaCICNESS MATERIAL
List all applicable well construction permits t?.e.UIC,County,State, Variance,etc.) R• ft. in,
3.Well Use(check well use): ft. ft. in,
water Supply well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
lA:GROUT
Agricultural
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rr. 20 Grout Poured
Monitoring Recovery
Injection Well:
Aquifer Recharge [3Groundwatcr Rcmcdiation
19.SAND/C RAVE C PACK''fa"'liedblc
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG,attacli additional sheets If nkeisaryj-
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRiPTTON color,eardn solUrock rain sin eta
0 n 65 't• Dirt
4.Date Well(s)Completed:2-17-2021 well ID# 65 It- 2451 Rock
5a.Well Location: ft. ft.
D & E Properties Linday Dellinger ft. >t.
Facility/Owner Name Facility ID#(if applicable) ft• ft.
3636 Kimber Lane, Sherrills Ford, NC 28673 ft n MA
Physical Address,City,and zip ft• ft. ssina Unit
Catawba 21.REMARKS inn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.CeCdfification:
35' 35.520' N 081' 00.227' W
3- Zoz/
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Ja No with I SA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
f this is a repairr fill out known well construction information and explain the nature of the copy 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 site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3(a,)200•and 2(a 100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Drilled above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air 24c.For Water Suaoly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 2/3 Cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016