GW1-2023-00442_Well Construction - GW1_20230109

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 50 ft- 245 ft-
ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 52 ft- 6.25 in SDR21 JPVC
Company Name
WELL-08-2022-178884 INNER CASING OR TUBING(geothermal closed-loop)
FROM
2.Well Construction Permit#: FROM TO 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• 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.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
DIrrigation ❑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:
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 ❑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 DESCRIPTION(color,hardness,soilfrock a rain size,etc
0 fr. 47 ft. Dirt
4.Date Well(s)Completed: 11-23-2022 well ID# 47 ff• 245 ft• Rock
5a.Well Location: ft. ft
t6•.v.i 1i.� it_^e� ;1
Jesse Freeman fL ft. JAN 0 n
Facility/Owner Name Facility ID#(if applicable) % ft. LJ
2357 Hendrix Rd, Maiden,,NC 28650 ft ft. 10�,.�,: s_�.
Physical Address,City,and Zip ft. ft.
Catawba 21.REMARKS
Couny Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Ce tification:
36' 60.531' N 081' 173.240' W - 11/23/2022
6.Is(are)the well(s): APermanent or ❑Temporary Signature of Certified We ontractor 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 IlNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction 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 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@200'and 2@I00)
10.Static Water level below top of casing: 50 (ft.)) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level above casing,use op
11.Borehole diameter: 6.25 (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drilled Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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(gin).10 Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 2/3 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018