GW1--03172_Well Construction - GW1_20230505

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. 185 ft.
ft. ft.
NC Well Contractor Certification Number Inc. 15.OUTER CASING for multi cased wells OR LINER(if a licable
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
ft, 72 ft. 6.25 in- ISDR21 JPVC
Company Name
W ELL-02-2022-166369 FROM
INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FRont 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 11DResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri 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:
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 [I 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 TO DESCRIPTION color,hardness,soil(mck type,grain size,etc.)
0 ft. 67 fL Dirt
4.Date Well(s)Completed: 2-22-23 Well IDO 67 ft. 185 ft- Rock
ft. ft. .-.
5a.Well Location: ,'
Alexander Sigmon 'Bet. ft.
une i Ili Nofnes
Facility/Owner Name Facility ID#(ifapplicable) ft. fL MAY 0 2023
1140 Smyre Farm Rd, Newton, NC 28658 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:
(ifwell field,one lat/long is sufficient) 22. rtirication:
35' 63.051 N 081' 21 .810' W 4/3/2023
6.Is(are)the well(s): ElPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing lhisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or tNo 15A NCAC 02C.0100 or 15A 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 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: 185 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi_(Jerent(example-3@200'and 2@100')
50 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/Jwater level is above casing,use"+"
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: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: I r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H TC Amount: 1/2 C u p
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018