GW1-2022-10329_Well Construction - GW1_20221114

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 ►icable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 114 ft 6.25 in- ISDR21 1PVC
WELL-05-2022-172385 16.INNER CASING ORTUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. IL in.
3.Well Use(check well use): ft. It. 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.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO 5ATERIAL 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 ❑Storntwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sontrock typQ grain size,etc
0 ft• 109 ft Dirt
4.Date Well(s)Completed: 8-5-22 Well ID# 109 ft. 325 ff Rock
5a.Well Location: ft. ft
Erica Fraizer Jonathan Scronce ft. ft ��:' Ft n-r�
Facility/Owner Name Facility ID#(if applicable) ft. ft. " '�
Lwdr
1316 Molly's Backbone Rd, Catawba NC 28609 ft. ft Vg = euzz
Physical Address,City,and Zip ft. ft. iwormw an
Catawba 21.REMARKS x
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ia tlong is sufficient) 22.Certification:
35.657.020' N 80.984.650 W 10/21/2022
6.Is(are)the well(s): WPermanent or ❑Temporary SignAture ofCcrtified 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
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: 325 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
�j0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fI•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
II.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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test•AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 3/4 cup
Form GW-1 North Carolina Department of environmental Quality-Division of Water Resources Revised 6-6-2018