GW1-2021-00463_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
FROM ft. TO CN1r110N
Well Contractor Name
• 200 R UES
3254 A 60
n. n.
NC WCII Contactor Ccniflcation Number 15.OUTER CASING far mold-casedwells OR LINER ifa Ilcable
Russell Well Drilling, Inc. FR1151 ftI DIA>IETE0. rHIC6..11 M.ITRRIAL
0 ft" 76 ft 6.25 In SDR21 I PVC
Company Name 16.INNER CASING OR TUBING eorbem ral closed-too
2.WellConstructionPermitq: Well-OS-ZOZO-133048 mom I TO DtiOdETER I THICKNIss I MATERIAL
List all applicable civil conenverton pe,mits(i.e. U1C Counq,.State, Vm-iance,err)
3.Well Use(check well use): ❑. n,
Water Supply Well: V.SCREEN
PP Y FltOM TO DIA]fETER SL SIZE TRI OT CK MATERIALNESMATERIALAgricultural []Municipal Public R. ft. in.
Geothermal(Heating/Cooling Supply) E)Residenlial Water Supply(single) ft. ft.
Industria/Conti nercial ❑Residential Water Supply(shared) 18.GROUT
_11irrigation FROM TO MATE1l1AL ENn'LACEMF.N I METHOD&AMOUNT
Non-Water Supply Well: 0 n- 20 f'' Grout Poured
Monitoring Recovery ft. ft.
Injection Well:
a. n.
Aquifer Recharge [)Groundwater Remedialion
1RSAND/GRAVEL PACK mopIkablc
Aquifer Storage and Recovery [3Sahnity Barrier FROM TO MATERIAL EMPLACEMENTh1ETHOU
Aquifer Test 13Stortnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attachaddl0ooals6eetsifnecefsa
Geothermal fleatin �Coulin Return) nOther(explain under H21 Remarks) I FROM TOI DESCRIPTION l,iflor,hardnre, sollovsk 011, ,.at sbe,cu.)
0 n 71 B- Dirt
4.Date Wallis)Completed: 1-6-2021 Well ID# 71 h 200 D' Rock
Sit.Well Location: ft. n
D & E Properties Mark Dellinger ft. ft.
Facility/Owucr Name Faciho Iof otapplieable) ft. n.
3644 Kimber Lane, Sherrills Ford, NC 28673
Physical Address,City,and Zip ft. n.
Catawba 21.REMARKS
County Parcel Idennficatiun
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if,vell field,one lao'long b sufficient) 22.Carl 35sufficient)35 56.551' N 081' 00.207' W 1-18-2021
6.Is(are)the well(s)oPermanent or Temporary Signature of certified'WeNWoutmelor Date
R,signing in,,Jorm. I hereby cmiiy the,the cello) nos(were)cormriewd is accordance
7.Is this a repair to an existing well: Yes or MNo vith I14 NCAC 02C 0100 or 154 NCAC 02C 0200 Well(ansn..tma Srandm'ds and char,,
I/rho,,u repair,0R om knmrrr o,ll,oa,cocoon i f..rear ua and e,plain the nacurr a fthr r»pr of thiv record has been prin Wed m the n ell o)vner.
repair under 421 remarks section or an the back of ouc form.
23.Site diagram or additional well details:
S.For Geoprobe/DPI'or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary,
drilled: SUBMUFFAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Pw inuldple writs bo all depths p,lmerenr(rxample-3(�00'and 2r0,10(7) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
IJ,oater leval fs above casing.ma 1617 Mail Service Center,Raleigh,NC 2 769 9-1 617
11.Borehole diameter: 6.25 (in.) 24b. For luiection 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 posh.etc.I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 636
13a.Yield(gpm) 10 Method of test- Air 24c r W ter Su alv & Infection Wells: In addition to sending the form to
CU
,�6) tf ress(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1/2 cup� � completion of well construction to the county health department of the county
where constructed.
Form G W.i North C'anchic,Department of F.nvimnmental Quality-Division of W ater Resources Revised 2-22-2016