GW1--04666_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD (CAW'-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 60 ft• 425 it.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. 78 ft. 6.25 in. SDR21 PVC
Company Name
Well-02-2023-189074 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.
ft. ft. in.
3.Well Use(check well use):
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑i rigation ❑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.
El Aquifer 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.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 f,, 73 ft. Dirt
4.Date Well(s)Completed: 4-16-2024 Well ID# 73 ft. 425 ft• Rock _
5a.Well Location: ft, ft. v.r 4, * ..a,
David Morgan Nelson Dellinger ft. ft. I(,
Facility/Owner Name Facility 1D#(if applicable) R. ft. ( S 2024
2710 Community Rd, Claremmont, NC 28610 ft. fL _ II.:.::,4• •'•rra 4 r1 Us*
Physical Address,Lit .❑nd lip ft. ft. (ff t•s L'G
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 edification:
35.758.090' \ 81 .166.84' W izz:., ..leszvaL 7/8/2024
6.Is(are)the well(s): Permanent or ❑Temporary St 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 I,No 1SA 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 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: 425 (IL) 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: 60
(fL) 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:A I r Drilled
24e.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
Air
Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) 1 00 Method of test: A I r
13b.Disinfection type: H fT C Amount: 1 1/4 Cup
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018