GW1-2022-03819_Well Construction - GW1_20220404

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 60 ft- 325 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells OR LINER if a licable -
Russell Well Drilling, Inc. FROM TO DIAMETER ! THICKNESS MATERIAL
0 ft. 55 ft. 6.25 i in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING'(eothermal closed400) .
2.Well Construction Permit#:WELL-12-2020-142797 FROM TO DIAMETER . I 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.
17.SCREEN.
Water Supply Well: _..... _ ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) $Residential Water Supply(single) ft. ft. 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. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19.SAND/GRAVEL:PACK.if:a Gcable
❑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),,
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return). ❑Other(explain under#21 Remarks) 0 ft- 47 ft- Dirt
4.Date Well(s)Completed: 3-2-2022 Well ID# 47 ft 325 It- Rock
5a.Well Location: ft ft
Adina & Csaba Kulcsar ft. rt. !,
Facility/Owner Name Facility ID#(if applicable) ft. ft 1'n
3387 Old Catawba Rd, Claremont, NC 28610 ft.
Physical Address,City,and Zip ft. ft
Catawba 2LREMARKS
County Parcel Identification No.(PIN) u .vO� ^" 1v"�q 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
C
rf well field,one lattlon sufficient f
g�is ) 22. tification:
35' 42.236' N 081' 08.119' W I/ . 3/14/2022
6.Is(are)the well(s): jaPermanent or []Temporary Signature of Certified Well Contractor I 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 11No 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 ofthe ofthis 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).Yot'l may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325 (ft)
For multiple wells list all depths if different(example-3@200'and 1@100) Submit this GW-1 withjn 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: 60 (fL) Information Processing Unit,1617 SC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: Copy to jDWR,Underground hnection Control(TUC)
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
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm)20 Method of test:AI r � •
13b.Disinfection type: HTH Amount: 3/4 cup
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018