GW1-2022-08775_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14:WATERZONES:
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft. 245 ft.
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING'foctriuld cased*ells OR:LINER if a `"Ilcable' =
Russell Well Drilling, Inc. FROM TO DIAMETER TJICIOVES3 MATERIAL.
0 ft• 73 ft 6.25 i in. SDR21 PVC
Company Name 16iINNER'CASING'OR.TUBING' eothermal'closed-loo '.
2.Well Construction Permit#: WELL-04-2022-169162 FROM TU DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Yariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN
FROM I TO DIAME TER z SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n g in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18;'.GROUT.
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Grout Poured
❑Monitoring ❑Recovery it. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge, ❑Groundwater Remediation
19:SAND/GRAVEL•PACK=if:ii' licable .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRILI IlVG•LOG attach iidditionel sheets';if necessa"
.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock e, rain size,etc.)
0 ft. 68 IL Dili
4.Date Well(s)Completed: 7-1 1-22 Well Dg 68 fL 245 ft. Rock
Sa.Well Location: ft. ft. r>T.
Clayton Homes f° ft. >.;,2 C�� ,���
Facility/Owner Name Facility ID#(if applicable) ft fL
2905 Wilderness Trace, Claremont, NC 28610 ft rt -
Physical Address,City,and Zip ft. ft. lnlori`ti3!�C:l ';Pr-,� az!ng Untt
Catawba 21-.REMARKS�' rs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.C cation:
35' 80.082' N 81' 16.416' W - 8/11/2022
6.Is(are)the well(s): ®Permanent 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 1!lNo 1 SA NCAC 02C.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 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).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 if different(example-3 e@200'and 2Qa 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
It.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 producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1011
13a.Yield(gpm) Method of test: i r j
13b.Disinfection type: HTH Amount: 2/3 cup !(
r
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018