GW1-2022-08772_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONESi-1: F`
FROM TO .'DESCRIPTION .__..
Well Contractor Name
3254 A 60 ft 245 ft-
ft. fL
NC Well Contractor Certification Number 154;01TER'CASING formdlh cased wells:OR liINER`If:a`Iicable) "=
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 87 16.25 ISDR21 JPVC
Company Name
416::INNER CASINGOR'TUBING eothe�mel closed-lob
2.Well Construction Permit#: WELL-1 1-2021-161226 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. It. in,
3.Well Use(check well use): ft M In,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft in•
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ft. ft. In.
OIndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL-,PACK,,If,a"lideble .
❑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 20rDRILLING LOG'iittiicti'ed8itional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc
0 ft 82 fL Dirt
4.Date Well(s)Completed: 7-1 3-22 Well DO 82 ft 245 ft ROCk
rr+
5a.Well Location: ft ft +�- - -ti Iv
Steven Marlowe Sedgewick Homes ft ft. _
Facility/Owner Name Facility ID#(if applicable) ft ft
4200 Caldwell Rd, Newton, NC 28658 ft ft ,rt;Lflx;;. on 'mc. ttgUtsli
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) 2M�0�4-j
35' 37.613' N 081' 06.709' W8/4/2022
6.Is(are)the well(s): OPermanent or ❑Temporary SigTmturt 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 ONo 15.4 NCAC 01C.0100 or 15.4 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 I 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: 245 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdderent(example-3@200'and 2@100)
10.Static water level below top of casing: 60 (f>;) 24a. For All Wells: Original foI to Division of Water Resources (DWR),
"+^ Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater 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 producingiover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Wm) 25 Method of test•Ai r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 2/3 Cup E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018