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Home My WebLink AboutWELL-08-2021-156280.TIF WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Chris C Russell 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name 3254 A 8 n• 285 ft• ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap Ruble) Russell Well Drilling, Inc. FROM 70 DIAMETER THICKNESS MATERIAL 0 ft* 77 f- 6.25 la• SDR21 PVC Company Name WELL-08-2021-156280 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIA I. List all applicable well construction permits(i.e.UIC.County.State.Variance.etc.) ft. ft. lc 3.Well Use(check well use): ft. It. in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SITE TIUCKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft. ft. in. ❑Geothermal(HeatingiCouling Supply) Iil Residential Water Supply(single) R. ft. in. DlndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT ❑lnigation 0 Wells> 100,000 GPD _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft* 20 it. Grout Poured ❑Monitoring ❑Recovery ft. n. Injection Well: ft. ft. DAquifer Recharge ❑Groundwater Remediation 19.SAND/CRAVEi.PACK(if applicable) °Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METIIOD DAquifer Test OStonmwater Drainage n• n. J❑Experimental Technology ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) ❑G(xrthermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cobs,hardness snlUrock type rain wi,eu.) 0 n• 72 it. Dirt 4.Date Well(s)Completed: 6-13-22 Well ID# 72 rt. 285 rt. Rock rt. ft. 5a.Well Location: Christian Mura It. ft. Facility/Owner Name Facility lOt(if applicable) H. R. 6904 Greedy Hwy., Hickory, NC 28602 n. ft. Physical Address,City,and Zip II. rt. Catawba 2t.REMARKS County Parcel Identification No.(PIN) Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22,Cgrtlt ation: 35' 64.020' N 081' 41.235' W /l/�� ,eel, g-t-e-i 7/29/2022 6.is(are)the well(s): ®Permanent or OTemporary Signature of CeAiiied Well Contractor Date By signing this farm.I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or IaLNo 1 SA NCAC 02C.0)00 or iSA NCAC 02C.0200 Well Construction Standards and that a copy if this is a repair,fill oat known well construction mfrnamtior and explain the nature of the of this record has been provided to the well owner. repair under N21 remarks section or on the hack of this form. 23.Site diagram or additional well details: 8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well construction info construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary. drilled: 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface:285 (ft.) Submit this GW-1 within 30 dayswell completionthe following: For multiple wells list all depths if different(example-3 di�00'and 2@ l00') of per ow g' 8 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: (rt) information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617 if water level is above rasing.use"+" 11.Borehole diameter: 6.25 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC) ,1 Program, 1 636 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,notary,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) Method of test:Air 30 Permit Program, 1611 MSC',Raleigh,NC 27699-1611 13b.Disinfection type: HTH Amount: 2/3 cup Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6(t-2011f l 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 8 ft• 285 It. 3254 A ft. Is. NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap Ucable) Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL 0 ft. 77 rt. 6.25 ''• SDR21 PVC j Company Name 2.Well Construction Permit#: W ELL-08-2021-156280 1b.INNER CASING OR TUBING(geothermal closed-loop) FROM TO DIAMETER THICKNESS MATF.RIAI. List all applicable well construction permits a e.U/C,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 ❑Agricultural OMunicipal/Public ft, ft. in ❑Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. tt. in. ❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 f4 20 ft- Grout Poured ❑Monitoring ❑Recovery ft. ft. Injection Well: ❑Aquifer Recharge ❑Groundwater Remcdiation ft. ft. 19.SAND/GRAVEL PACK(If applicable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD °Aquifer Test DStormwater Drainage IL n. ❑Experimental Technology ❑Subsidence Control ft. it. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additions!sheets If necessary) ❑Geothermal(fleeting/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO IWSCRITTION(color,hardness,snti/rock type,fain size.etc.) 0 n• 72 ft. Dirt 4.Date Well(s)Completed: 6-13-22 Well ID# 72 ft. 285 rt. Rock R. ft. 5a.Well Location: Christian Mura ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. rt. 6904 Greedy Hwy., Hickory, NC 28602 ft. ft. Physical Address,City,and Zip ft. ft. Catawba 21.REMARKS County • Parcel Identification No.(PIN) Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lot/long is sufficient) 22/(,;grti anion: 35' 64.020' N 081' 41 .235' w J 1 .644.2-t- i 7/29/2022 6.Is(are)the well(s): lPermanent or ❑Temporary Signature ofCertititxl Well Contractor Date By signing this form,I hereby certify that the wen(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: °Yes or No 1.fA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,Jill alit known well constructions infnrnmtirnt and explain the nature of the of this record has been provided to the well owner. repair under#2!remarks section or on the hack 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: 285 (fC) Submit this GW-1 within 30 days of well completion the following: For multiple wells list all depths if different(example-3(df 00'and 2 t@i!00') P per 8 24a. Fur 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 If water level is above casing.use'•+" 11.Borehole diameter: 6.25 On.) 24b. For Inlectlon Wells:Copy to DWR, Underground Injection Control(IUC) Program, 1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: Air 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 producin;over 100,000 GPD: Copy to DWR,CCPCUA 13a.Yield(gpm) 30 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1 13b.Disinfection type: H IT H Amount: 2/3 cup Form G W I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2011