GW1-2022-10703_Well Construction - GW1_20221205

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRH'TION
Well Contractor Name
8254 A � 50 fc• 165
�•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a 0cable
Russell Well Drilling, Inc. FNOM TO DIAMETER THICKNESS MATERIAL
0 fr. 48 ft. 6.325 i" SDR21 JPVC
Company Name
Well-06-2021 152321 16.INNER CASINGORTUBING eothermaldosed
2.Well Construction Permit#: FROM TO DIAMETER I 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. 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
❑hri 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:
it. 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 ft. 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 DESCRIPTION color,hardness,soiUrock a rain size,etc.)
0 ft. 43 ft. Dirt
4.Date Well(s)Completed: 10-7-2022 Well ID# 43 ft' 165 ft- Rock
ft. ft.
5a.Well Location:
Brian Collins Sedgewick Homes rt ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. -r '�
391'5 25th Ave NE, Hickory, NC 28601 ft. ft. r6
Physical Address,City,and Zip ft. ft
Catawba 21.REMARKS v `mil%J
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.C •'cation:
35' 78.298' N 081' 28.072' W 11/11/2022
6.Is(are)the well(s): laPermanent or ❑Temporary Signature of Certified well Nontractor 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 11No ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this 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 ofthis 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: 165 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifelifferent(example-3@200'and 1@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `50 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NO 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
13a.Yield(gpm)40 Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018