GW1-2022-00938_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 TO DESCRIPTION
Well Contractor Name rt. ft. {
4545-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER s llcabie
CAMP'S WELL&PUMP CO., INC. FROM To DIAMETER TrDcicNEss MATERIAL,
0 ir- 1 90 ft. 6.125 i° SDR21 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
2.Well Construction Permit#: SW21-0321 FROM TO DIAMETER I TilICIOMS 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.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE TtHCICNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) h ft. in•
Industrial/Commerciai DResidential Water Supply(shared) W.GROUT
Irrigation 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 19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO DI MATERL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage B• rt.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soll/rock type,gizin size,etc.
Geothermal(Hea ooling Return) Other(explain under#21 Remarks
0 ft- 90 R• CLAY
4.Date Well(s)Completed:11�_M_Ili Well ID# 91 ft' 505 it• GRANITE
5a.Well Location: rt. ft.
MICHAEL BYARS ft' ft'
Facility/Owner Name Facility ID#(if applicable) ft. ft,
833 OWENSBY RD. ft. rt tf'" ;'(� F—
_.
Physical Address,City,and Zip rt. ft.
RUTHERFORD 21.REMARKS 1027-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.444314 N -82.057503 W
6.Is(are)the well(s)OPermanent or DTemporary Si of Certified ell Contra r_ Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ®No with 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
If this 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: 505 00 24s. 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©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 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection 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 Cyenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test:
AIR 24c.For Water Supply&Iuiection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: Amount: p
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016