GW1--02109_Well Construction - GW1_20240405

I
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 40 ft• 365 ft• I i
ft. ft. I I
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. 72 ft. 6.25 i i in. SDR21 PVC
Company Name _
WELL-23124-01 • '16.INNERCASING 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. i , in.
3.Well Use(check well use): ft. ft. i in.
Water Supply Well: 17.;SCREEN
_FROM TO DIAMETER_ SLOT SIZE THICKNESS MATERIAL -
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) llResidential 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 ft' 20 ft. Grout`:' Poured
❑Monitoring DRecovery ft. ft.
Injection Well: - ft. ft.
DAquifer Recharge ❑Groundwater Remediation '
,19.;SAND/GRAVEliPACK(if applicable)==-_ .• . - "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology OSubsidence Control ft. ft. l'
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach'additional sheets if-necessary) ' ,.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock/rock type,grain size,etc.)
,1 0 ft. 67 ft. Dirt
4.Date Well(s)Completed: 3-4-2024 Well ID# 67 ft. 365 ft• Rock i
5a.Well Location: ft. ft. •
Claudiu Daniel Belos ft. ft. i Li,r: V .1 J
Facility/Owner Name Facility ID#(if applicable) ft. ft. i, /; ,n
1360 Sain Rd, Hickory NC 28602 ft. ft. APR Z cG
ft. ft. in c.cmrU.;l,-*r"'- 5c=4,:ri UFi
Physical Address,City,and Zip a"
Catawba :21.REMARKS ."l`'t 0t
County Parcel Identification No.(PIN) l' '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification:
35.663.95' N 81.353.53' w (? iee 3/19/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor 1 Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repairto an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 1SA 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. k
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
365 1
9.Total well depth below land surface: (ft.) I'
For multiple wells list all depths if different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
40 24a. For All Wells: Original for;to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,16171\4SC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6.25 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Openi'Loop Geothermal Return Wells:Copy to the
(ie.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 lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 8 Method of test:Air
13b.Disinfection type: HTC Amount: 1 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource , Revised 6-6-2018