GW1-2021-02118_Well Construction - GW1_20210709

r Print Form
i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C. Russell r-1r_r_,PWF_D 14.WATER ZONES
Well Contractor Name X FROM 'to UESCR1 TION
3254 A 2021 60 ft 600 ft•
J U L 4 ft. ft.
NC Well Contractor Certification Number
processing 15.OUTER CASING for multi-cased wells OR LINER if a licable
Russell Well Drilling, Inc. Infolm3tlOn P FROM TO DIAMETER THICKNESS MATERIAL
^�tR section 0 ft. 80 ft• 6.25 i" SDR21 PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-too
04-2021-148214
FROM TO DIAMETER
2.Well Construction Permit#: METER TRICKN-ESS MATERL9I,
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: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in-
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft Grout Poured
Monitoring Recovery
Injection Well:
:]Aquifer Recharge DGroundwatcr Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness solUrock type,grain size ctc.
0 it 75 ft- Dirt
4.Date Well(s)Completed:5-18-21 Well ID# 80 ft- 600 iL Rock
5a.Well Location: ft. ft.
Harrington Witherspoon
Facility/Owner Name Facility m#(if applicable)
2600 JB Rd, Claremont, NC 28610
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 lat/long is sufficient) 22.Certification:
35' 42.480' N 081' 07.365' W ,
6.Is(are)the well(s)OPermanent or OTemporary SYglistore of Certified Well Contractor Date
By signing this form.I herebv certify that the well(s)svas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or O No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well cows-uetion 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:
R.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: 600 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list/all depths ifdiJjerent(example-3(a3200'and 2@1001 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 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) 2 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: 2 2/3 Cups 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