GW1-2022-01223_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES,
FROM TO DESCRIPTION
Well Contractor Name
3254 A 60 ft• 205 rt.
ft. ft.
NC Well Contractor Certification Number Inc. -15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, c FROM TO DIAMETER TffiCKNESS MATERIAL
0 it- 70 ft- 6.25 In- ISDR21 JPVC
Company Name
Well-08-2021-156281 16.INNER CASING ARTUBING(geothermal closed-too "
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) ❑Residential Water Supply(single) g• g• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Grout Poured
❑Monitoring ❑Recovery ft. IL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
99.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL 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,soil/rock typc rain size,etc.)
0 ft. 65 ft Dirt
4.Date Well(s)Completed: 12-9-2021 well ID# 65 ft- 205 ft- Rock
5a.Well Location: ft. ft. 14 p .h RV
Sherrills Ford-Terrell Fire&Rescue Jason Wood ft. rt.
i ft.
Facility/Owner Name Facility ID#(if applicable) ft. --
2080 Molly's Backbone Rd, Sherrills Ford, NC 28673 et. rc. IMSETO
Physical Address,City,and Zip ft. ft. Ir J_CMA f t P'TIESSIWG h!I
Catawba 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35' 38.162' N 080' 58.023' W 12/15/2021
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !1No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If 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-I 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: 205 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list al/depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
f 0.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.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 L1 Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: UTL_I Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018