GW1-2021-00998_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14swATER`ZONEs
FROM TO DESCRIPTION
Well Contrdctor Name 60 ft 205 ft.
3254 A
rr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIA METER THICKNESS MATERIAL
Company Name 0 ft 63 ft 6.25 i SDR21 PVC
Well-01-2021-$$39$6 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O J O FROM TO DIAMETER TMCKNESS 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: FR SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. la
Industrial/Commercial Residential Water Supply(shared) 18.`GROUT
1nT ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 Grout Poured
Monitoring Recovery
injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer '20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness so] rock type,grain size etc.
0 it 58 ft• Dirt
4.Date Well(s)Completed: 3-10-2021 Well ID# 58 it 205 ft. Rock
5a.Well Location:
Avery Jones Jonathan Scronce
Facility/Owner Name Facility[D#(if applicable)
2644 Weaver Rd, Newton , NC 28658
Physical Address,City,and Zip ft. ft.
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: .�
35' 36.844' N 081' 19.721' W (Y41J-1 /C«a4c.Cl_
3-18-2021
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis 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:
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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(a3100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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) 30 Method of test: Air 24c.For Water Supply&Infection 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: 1/2 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