GW1-2022-01816_Well Construction - GW1_20220218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi=cased wells OR LINER if a licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 1 130 ft- 6.t25 1O' SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) n. tt. 1n•
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT I
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well: ft.ft. .
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardoess,soiVrock a rain size,etc.
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft. 1 130 ft• CLAY
4.Date Well(s)Completed: Well ID# 131 ft. 205 ft, GRANITE
ft. ft.
5a.Well Location:
SCOTT HUDSON
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. `
UN RIVER CLUB RIDGE, LENIOR rt. rt. I g FFR2n29
Physical Address,City,and Zip
CALDWELL 21.REMARKS
County Parcel Identification No.(PIN) - mmimmmmoi,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.897537 N -81.679721 W
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6.Is(are)the well(s)opermanent or DTemporary Signature of Certified Well Contractor(/ DDate
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 E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction.Standards and:hat 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 e@200'and 1(a)100) construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.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 Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 50 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
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction',to the county health department of the county
where constructed. N
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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