GW1-2021-00464_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
Well Contract.,Name FROM TO UPSCWP'IION
3254 A 60 D• 200 R
rt. R.
NC Well Contractor Certification Nmnber 15.OUTER CASING f gut.naed wellb OR LINER ifs livable
Russell Well Drilling, Inc. FROM Ft1 OIAaIETEis THICKNESS 61nTERInL
Company Naine 0 in. 176 "• 6.25 `n• I SDR21 I PVC
WELL -05-2020-133051 16.INNER CASING OR TUBrNG eothermal cased nano
2.W¢II Construction Permit#: FROM TO I DWIETER THICKNESS MATEKW.
List all applicable well eamvuctien permits(re. U1C,Counry.State, Variance.eh7 ft. h, in.
3.Well Use(check well use): ft. ft. In,
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER I SLOT SIZE TRICKNE55 MATERIAL
Agriculmml QMunicipaLTublic ft. ft. in.
Geothermal(Heating/cooling Supply) ®Residential Water Supply(single) b O• in.
Industriai/Commercial Residential Water Supply(shared) IE.GROUT
71 Irrigation FROM TO MATERLll, EMPLACEMENT METROD&.AMOUNT
Now Water Supply Well: 0 A. 20 D' Grout Poured
Monitoring DRecovery
Injection Well:
Aquifer Recharge [3Groundw'atcr Rcmcdiation
19.SAND/GRAVEL PACK(ifs be
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. h.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tmcer 20.DRULING LOG Winch additional sheets if seminary)
GWthermal(HeatuatiCcoling Rehm Other(explain under 421 Remarks) mom TO DESCRIPTION talor,hanso .]U.k wp,,grain sire,eta.
0 ft 71 R• Dirt
4.Date Well(s)Completed:01-05-2021 3Yeu ID# 71 f 200 D• Rook
5a.Well Location: A. f.
D 8r E Properties Keith Estes ft. D•
Facility/Owner Name Facility ID#(ifapplicable) ft. D,
3640 Kimber Lane, Sherrills Ford, NC 28673 ft. n.
Physical A4dreaa,City,and Zip ft. D.
Catawba 11.REMARKS
Cuunly Parcel Identification Nu.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one la/long issudcieut) 22.0 reification:
3635.5291 N 081' 03.233' W ?Q�aca 1-20-2021
6.1s(are)thewell(s)OPermanent or [)Temporary grMtwc ofCertificd Won Corimacmr Date
By signing This form.1 hereby cenffv liar the v,el1(s)was(were,cmm,vnea in a,cordance
7.Is this a repair to an existing well: OYes or [:)No with )5.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Canunvotlon Slandurds and that a
lJlhB is a mpuiq�l]our knrnvn well onaruvcliun Infrrrmattou and erphnn the mlure of the eopr of thi,record has been provided to the,.ell moue,,
repair under#21 remarks section or on Ile back of This form.
23.Site diagram or additional well details:
K.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-1 is needed. Indicate TOTAL NUMBER of wells constmction details. You may also attach additional pages ifnecessary.
drilled: _. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (fed 24a. For All Wells: Submit this form within 30 days of completion of well
For nidu,reweilx0:unl/depth.,ifduleenr(esample-3(g200'and lnil(/rl')) y ^ g021 construction to the following:
10.Static water level below top of casing: 60 1 eU } C(ft.) Division of Water Resources,Information Processing Uniq
1Jwaler/eve!!s above caring.iue`+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Air Drilled above, also submit one copy of this t'onn within 30 days of completion of well
l2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct posh.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 Sunniv& Iniection Wells: In addition to setdhrg the form to
the address(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-1 North Camlina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016