GW1-2021-07659_Well Construction - GW1_20211215

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ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name tt, ft.
4545-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ff a licable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 ft• 9a ft 6.125 in' SD1221 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:W2 1-0408 FROM To ft. In.DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
[t.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. tt. fin•
Geothermal(Heating/Cooling Supply) oResidenfial Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hTl atl0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Monitoring Supply Well: 0 R. 20 ft. BENTENITE -POURED 14 BAGS
ft.Recovery tt. .
Injection Well:
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage tt. It. I -_ i
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets H necessary)
FROM TO DESCRIPTION color,hardness aMil-k rain a etc.
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks 0 ft. 98 % CLAY
4.Date Well(s)Completed: 99 ft. 165 ft. GRANITE
ft. ft.
5a.Well Location:
JAMES CABLE ft. ft.
Facility ID# ifs licable ft. ft. ;Alf_f
Facility/Owner Name tY (• PP )
215 FRENCH MTN. DR. ft. tr.
Ft. ft. '
9021
Physical Address,City,and Zip
MCDOWELL 21.REMARKS MRi?Wiiw t
County Parcel Identification No.(PIN) tIs,u,�rrnae,G;,, -•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Is
Certitie
35.598492 N -82.033456
amre o ertified Well Contractor Date
6.Is(are)the well(s)�IX, Permanent or Temporary
igni this fonn,I hereby certify that the wells)was(were)constructed ir.accordance
7.Is this a repair to an existing well: Yes or EX No I NCAC 02C.0100 or 15A NCAC 02C.0200 Well Const uctiau Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the
copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (110 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 20 Method of test: AIR 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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