GW1--02819_Well Construction - GW1_20240506

1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris C Russell ,14.,WATERZONES . ' . '
Well Contractor Name FROM TO DESCRIPTION
3254 A 150 ft• 705 ft. 1
fa ft.
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabte) '. _
Russell Well Drilling Inc FROM TO DIAMETER' I THICKNESS MATERIAL
Company Name 0 ft. 100 ft. 6.25 I i" SDR21 PVC
W E L L240314-02 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. 117.SC in.
Water Supply Well: FR MBEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in. 1
0 Geothermal(Heating/Cooling Supply) IlResidential 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
OMonitoring ❑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. i
' DExperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
- FROM TO DESCRIPTION(color,hardness,sotVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft* 100 ft. Dirt
4.Date Well(s)Completed: 3-20-2024 Well ID# 100 ft• 705 ft• Rock
ft. ft.
5a.Well Location:
Colby Bolick ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. .t., .• -_';•i A'4-- j 1
4485 Lookout Dam Rd, Catawba NC 28609 ft. ft. MAY V�pp
Physical Address,City,and Zip ft. ft. C [GL4
Catawba 21.REMARKS,. - 1G:, -?; ,- ,
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: •
35.692.55' N 81 .044.43' W C. 44.0.zix 4/19/2024
6.Is(are)the well(s): OPermanent or OTemporary Signature of Certified Well Contractor 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 ONo /5A 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 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: 705 (fk) 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')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1`5Cn 0.4 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
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
13a.Yield(gpm) 30 Method of test:Air
Permit Program,1611 MSC,Raleigh INC 27699-1611
13b.Disinfection type: HTC Amount: 2 3/4 cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018