GW1-2022-01134_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft. 225 ft
ft. ft.
NC Well Contractor Certification Number Inc. -_15:OUTER CASING for multi-cased wells OR LINER if a Hcable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 51 ft- 6.25 SDR21 JPvc
Company Name WELL-02-2021-146116 116.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) lilResidential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) •.18.GROUT
❑lni ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrrrwater Drainage ft. fL
❑Experimental Technology El 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,soiVrock type,grain size,etc.)
0 ft' 46 ft. Dirt a
4.Date Well(s)Completed: 12-16-2021 well ID# 46 ft• 225 ft- Rock
5a.Well Location: ft. ft. O
Richard Lail Sedgewick Homes ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
2354 Lynell St, Conover, NC 28613
Physical Address,City,and Zip
rt. ft.
Catawba 21.REMARKS
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' 48.799' N 081' 10.791 W - 12/31/2021
6.Is(are)the well(s): mPermanent or ❑Temporary
SignatuM of Certified Well Contractor Date
By signing this form,I hereby certifv that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
U'this 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: 225 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.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(gpm) 15 u u Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTu Amount: 2/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018