GW1-2023-01405_Well Construction - GW1_20230208

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 70 ft. 200 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ilcable
Russell Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p ft. 70 ft- 6.25 1" SDR21 PVC
16.WELL-08-2022-178035 FROM RCASING ORTUSIAM eothermalclICKNoo
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) RlResidential Water Supply(single) ft• ft in,
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
l2brigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 fl' 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 I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ftt
❑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 I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
p ft. 65 ft. Dirt
4.Date Well(s)Completed: 12-14-22 Well ID# 65 ft- 200 ft- Rock
5a.Well Location: ft. ft
D & E Properties Keith Estes ft ft'
Facility/Owner Name Facility ID#(if applicable) fL ft.
2023
3464 Stony Brook Lane, Sherrills Ford NC 28673 ft. ft.
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) 22.Certification:
35' 59.972' N 081' 04.845' W C`�� 1/12/2023
6.Is(are)the well(s): IJPermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning 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 8No ISA NCAC 02C.0100 or ISA 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 beenprovided 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: 200 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 1@100)
10.Static water level below top of casing: 724a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1.
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 producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test: I r JI
13b.Disinfection type: HTH Amount: 3/4 cup
I
Form GW-1 North Carolina Department of Envirorunental Quality-Division of Water Resources Revised 6-6-2018