GW1-2022-00930_Well Construction - GW1_20220107

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-WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A
rt. rt.
NC Well Contractor Certification Number .15.OUTER CASING for mold cased wells OR LIIVER if a licable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER TTIICICNESS MATERIAL
0 ft- 98 ft I 6A215 In SDR21 PVC
Company Name
16.INNER CASING OR TUBING eother al closed-loo
2.well Construction Permit#: SW21-0365 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. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaVF'ublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lITi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 It. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardn soil/rock type,grain size,etc.
0 ft. 98 ft. CLAY
4.Date Well(s)Completed: Well ID# 99 ft. 505 M GRANITE
5a.Well Location: ft.
JAMES ROSS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 7
107 ELLIOT RD. ft. ft.
Physical Address,City,and Zip i
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) Ya'G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fatllong is sufficient) 22.Certification:
35.459122 -82.036499
N W !�_1 . )-,
6.Is(are)the well(s)OX Permanent or ❑ITemporary Signature ofCertified Weill Contra r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X)No with 13A 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 (ft.) 24a. For All Wells: Submit ibis form within 30 days of completion of well
For multiple wells list all depths jdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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
P
13b.Disinfection type:
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016