GW1-2021-08152_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 100 �- 325 k•
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Ilcable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 36 ft 16.25 in SDR21 JPVC
Company Name 16.INNER CASING OR TUBING eotbermal closet1400
2.Well Construction Permit#: 0 1-2021-1 44259 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft in.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public ft N. in.
❑Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. R• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 Grout Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soltlrock in size etc
0 ff. 31 ft Dirt
4.Date Well(s)Completed: 9-29-2021 Well ID# 31 ft- 325 ft Rock
5a.Well Location: ft ft
Zachary Bruenger Sedgewick Homes ft ft
Facility/Owner Name Facility ID#(if applicable) % ft
9177 Reepsville Rd, Vale, NC 28168 ft ft.
Physical Address,City,and Zip ft ft.
SRCITION
Catawba 21,REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ;22.C rtifieation•
35' 33.904' N 081' 19.675' W ,,-, ;ellt,,
10/6/2021
6.Is(are)the well(s): COPermanent or ❑Temporary ftilaturo of Certified Welf1ftntractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a copy
/fthis is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@100'and 2@I00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljwater level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 6 Method of test•Ai r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH Amount: 2/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018