GW1-2021-00240_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT ',J4.WAT.ER,Z0NES.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A rL ft.
NC Well Contractor Certification Number 15:=OUTER'CA8ING;foi multiscas"ed°wells OR.I M rf i"licable a
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERLII.
0 ft- 63 ft, 6.125 In, SDR21 PVC
Company Name
SW20-0058 `16,INNER_C 1SING OR`TUBIIYG; edthermal closed;loo.< -- c. ..>
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.
L
Supply Well: FROM TODIAMETER SLOTSIZE THICKNESS MATERIALcultural [3Municipal/Public ft. ft. In.
hermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
strial/Commercial Residential Water Supply(shared)
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 ft. BENTENITE POURED 14 BAGS
Monitoring _ Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19SAND/GRAY.Eti'PAC1C.if a'"'Htable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
'Geothermal(Closed Loop) OTracer 20:*DRILL'ING`L'OC;sttaeti sd'dttioaal sfieet's_if necessa`
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soil/rock a rain 9 etc.
— / 0 ft. 63 ft. CLAY
4.Date Well(s)Completed: /" (Well ID# 64 ft. 505 ft, GRANITE
5a.Well Location:
TIFFANY KEMP
Facility/Owner Name Facility ID#(if applicable) ft. ft. t�t _r,
GRANDVIEW PEAKS DR.
Physical Address,City,and Zip ft. ft. C 1
MCDOWELL 2LREMARKS, ° -
County Parcel Identification No.(PIN)
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22, erl eeation•
35.568330 N -81.894147 W fl
6.Is(are)the well(s)OPermanent or .oTemporary C7WI,15A
e of CertifiedVWeontra6t6r Date
ng this form, y certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or JMNo NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction 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-i 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: 505 M-) 24a. For All Wells: Submit ithis form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 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 Iniection 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
13a.Yield(gpm) 50 Method of test: AIR 24c.For Water Sunaly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE. Amount: 2 CUPS completion of well construction to the county health department of the county
where cnnstrurled,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016