HomeMy WebLinkAboutWELL-08-2023-203684.TIF WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,WeIl Contractor Information:
Chris C Russell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3254 A 80 R' 325 rt. -
ft. rt.
NC Well Contractor Certification Number Inc. LS.OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Russell Well Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 102 n• 6.25 in' SDR21 PVC
Company Name lb.INNER CASING OR TUBING(geothermal claed-loop)
2.Well Construction Permit#: Ir if ELL-O8'2023�20�JV84 FROM TO DIAMETER 'THICKNESS MATERIAL
List all applicable well construction tion permits(i.e.VIC,County,Stare.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
0 Agricultural ❑Municipal/Public rt. ft. In.
°Geothermal(Healing/Cooling Supply) eiResidential Water Supply(single) ft. n. M.
❑Industrial/Commercial °Residential Water Supply(shared) IN.GROUT
❑Irrigation °Wells>100,000 GPO FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 ft. Grout Poured
❑Monitoring ❑Recovery ft. It.
Infection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test OStormwater Drainage ft. ft.
0 Experimental Technology ❑Subsidence Control ft. ^ ft.
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM to DESCRIPTION(eater,nsranftt,wltlrr rk type,grain slu,ot4)
r�
0 rt* 97 ft• Dirt
4.Date Well(s)Completed: 11-1 3-23 Well ID# 97 ft• 325 rt. Rock
ft. rt.
Sa.Well Location:
Mark Isenhour Construction, Inc. (Leland Eckard) ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. R.
6048 Lynchburg Rd, Hickory NC 28609 rt. ft.
Physical Address,City,and'Lip 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 latilut:g is sufficient) 22, tlflcation:
35.798.00' N 81 .232.60' wtur - 12/5/2023
6.Is(are)the well(s): Permanent or OTemporary
Signa ed Well C nlractnr Date
By signing this form,I hereby c er71fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill oat know,,well construction information aril explain the nature of the of this record has been provided to the well owner.
repair under 1121 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 OW-I 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: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple welts list all depths if different(example-34::200'and 2@100')
80
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: tit) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"1"
11.Borehole diameter. 6.25 (In.) 24b.For Injection Wells:Copy to DWR. Underground Injection Control (TUC)
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,NC 27699-1611
13b.Disinfection type: HTC Amount: 3/4 cup
Form 0 W-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-201 N