GW1-2022-07090_Well Construction - GW1_20220801

F
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DES ON
Well Contractor Name
ft. 200 ft.
3254 A so ft. ft
NC Well Contractor Certification Number 15.OUTER CASING'for multi ca5ed'welis OR LINER'd a "Ilcable
Russell Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft- 163 ft- 6.25 ISDR21 JPvc
Company Name
WELL-03-2022-167730 16.INNER:CASING ORTUBING eotbermal'closea-loop)
2.Well Construction Permit#: FROM I TO I 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. rL in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERML
❑Agricultural ❑Municipal/Public ft. k. in.,
❑Geothermal(Heating/Cooling Supply) 0OResidential Water Supply(single) ft. R. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.>GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 It. Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL SACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier 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 necessa`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIP'r1ON color,hardness,soil/rock type,grain size etc.)
0 ft 58 ft. Dirt ?--
4.Date Well(s)Completed: 6-14-2022 Well ID# 93 ft 200 fL Rock
5a.Well Location: ft. ft.
Keith Estes ft. ft Y
Facility/Owner Name Facility ID#(if applicable) ft ft. inklfl0r, an roc nft
3473 Storybrook Ln, Sherrills Ford NC 28673 ft. ft.
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' 60.025' N 081' 04.769' W 7/20/2022 e=� A4 z a.el
6.Is(are)the well(s): ft7Permanent or ❑Temporary ignaturc of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1!lNo 1 SA NCAC 01C.0100 or 15A NCAC 01C.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-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: 200 (ft) Submit this GW-1 within 30 days of well completion per the following:
Far multiple wells list all depths if different(example-3@200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: 80 Ift) 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,NCj 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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinj over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralei
13a.Yield(gpro) 50 Method of test: I r ',gh,NC 27699-1611
f
13b.Disinfection type: HTH Amount: 3/4 cup i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018