GW1-2022-03820_Well Construction - GW1_20220404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Chris C. Russell '14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 100 ft- 925 fr.
ft. ft. P
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a "licabte
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft• 57 ft- 6.25 in SDR21 JPVC
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It.
ft. - in.
3.Well Use(check well use): ft. I 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) ft. ft. in.
❑Industrial/Commercial ❑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
19.SAND/GRAVEL PACK if applicable)
"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL 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 type,grain size,etc.)
o ft. 52 ft Dirt
4.Date Well(s)Completed: 3-2 2022 Well ID# 52 It. 927 ft. Rock
Sa.Well Location:
ft. ft. j
Adina & Casaba Kulcsar ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft � � �1 am
3387 Old Catawba Rd, Claremont, NC 28610 ft. ft.
Physical Address,City,and Zip ft. ft. APR
Catawba 21.REMARKS
County Parcel Identification No.(PIN) "•' ^�`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Wit#EiJ Fr:�.rrvvarw
(ifwell field,one Iattlong is sufficient) 22.Certification:
35' 42.287' N 081' 08.119' W �J� 3/14/2022
6.Is(are)the well(s): faPermanent 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 ItNo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis 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: 925 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(r200'and 2@100D
100 24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater 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: AI r 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 departrirent 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,
13a.Yield(gpm) Method of test: I r NC 27699-1611
13b.Disinfection type: HTH Amount: 3 Cups
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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