GW1-2021-03294_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD(CW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPl-ION
3254 A
60 fL 405 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 130 ft. 6.25 `" SDR21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)"
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 6.e. 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 TRICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. £t. in
Industrial/Commercial DResidential Water Supply(shared) lg.GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Grout Poured
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge [DGroundwatcr Retncdiation
19:SAND/CRAVEL`.PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionalsheets if necessary).
,'Geothermal (Heating/Cooling Return) 00ther(explain under 421 Remarks FROM To DESCRTPTTON color,hardness soiUrock type,grain size etc.
0 ft- 125 ft. Dirt
4.Date Well(s)Completed:5-17-21 Well ID# 125 f`• 405 ft. Rock
5a.Well Location:
David Carpenter
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3051 Tucker Drive, Claremont, NC 28610 ft. ft. i Z
Physical Address,City,and Zip ft. ft. Unit
Catawba 21:REMARK D.
County Parcel Identification No.(PIN)
..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35' 49.902' N 081' 09.884' W �I-X
ll.... 5-25-2021
6.Is(are)the well(s)oPermanent or OTemporary 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: E]Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,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:
A.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 construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/is list all depths ifdijyerent(example-3L200'and 20,7)100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'.+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.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 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) 12 Method of test: Air 24c.For Water Supply&Iniection 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: 1 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