GW1--06368_Well Construction - GW1_20230927

1
I •
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information: { :
Chris C Russell 14.WATERZONES I
We1lContrac[orName FROM TO DESCRIPTION
3254 A 60 ft• 185 ft I j
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 44 ft• 6.25 :In. SDR21 PVC
Company Name
WELL-05-2023-195035 16.INNER CASING OR TUBING(geothermal closed-loop)
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
DAgricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 ft Grout Poured
❑Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothemral(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO ' DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 39 ft Dirt
4.Date Well(s)Completed: 8-24-2023 Well LD# 39 ft. 185 ft. Rock
5a.Well Location: ft. ft
ft. ft. '' E 'Z. -�J �•s J
John Kasier �z �'�._..:�,:.�. �`
Facility/Owner Name Facility ID#(if applicable) ft ft ' n 1-, L�L�
6270 Lynchburg Rd, Hickory NC 28601 ft ft. f
Physical Address,City,and Zip ft. ft. rC V l f;v r 3;'r lit f
]n. rsv
Catawba 21.REMARKS '.G4:`+:t
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. 803.50' N W (2.744_,- ��81 . 229.09' 8/31/2023
6.Is(are)the well(s): l!lPermanent or ❑Temporary Signature of Certified We 1 Contractor Date
By signing this form,I hereby cert((y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stdn'dards 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 if different(example-3@200'and 2@l00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 014 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water 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: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: I 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,;NC 27699-1611
13a.Yield(gpm) 50 Method of test:Air
13b.Disinfection type: HTC Amount: 1/3 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018