GW1-2022-01600_Well Construction - GW1_20220204

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WELL CONSTRUCTION RECdV-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name g, ft.
4545-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING forlti-cased wells OR LINER if a Ucable
CAMP'S WELL& PUMP CO., INC. FROM mu
To DIAMETER THICKNESS MATERIAL
0 ft. 55 ft. 1 6.125 in' SDR21 PVC
Company Name
16.1NNER CASING OR TUBING eothermal closed-loo
SW21-0564
FROM
2.Weil Construction Permit#: To DIAMETER THICKNESS MATERIAL
List all applicable wril construction permits(i.e.UIC,County,State,Variance,etc) h' ft. in.
3.Well Use(check well use): ft. ft.
Water So Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) h, ft.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 it• BENTENITE POURED 14 BAGS
Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
79:SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
ft. ft.
_Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return Other(explain under#21 Remarks I
FROM TO DESCRIPTION color,hardness,soWcock type,grain size,etc
0 h• 55 ft- CLAY
4.Date Well(s)Completed: Well ID# 56 ft 355 ft' GRANITE
ft. it.
So.Well Location:
ROBIN DAUM/JOHN HAMRICK
Facility/Owner Name Facility ID#(if applicable)
i
FREEMAN TOWN RD. ft. fL e
Physical Address,City,and Zip ft. ft.
Uzi
RUTHERFORD 21.REMARKS ��'y, -
County Parcel Identification No.(PIN) r rt�ME
l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.452641 N -82.106355 W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Co dor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ONo with 15A NCAC 02C.0100 or 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 retard 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: 355 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: 80 (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: hi 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: f
(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) 100 Method of test: AIR 24c.For Water Sunoly&I I iection 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 construct on 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