GW1-2022-03667_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT _M0WAmER=zortEs _ x � °•. .. 'm {
Well Contractor Name FROM TO DESCRIPTION
4545-A
ft. ft.
NC Well Contractor Certification Number IS QUTER"CsASING(ft+r?mult4casid"iwells',QRv .RR?if a"'Itcablb �s
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESs MATERIAL
0 ft- 100 ft• 6.125 � In' SDR21 PVC
Company Name '16`'�IINNER?l.1SING.OR�R',UBINGt eo'the'" I° "•"`'
EH-21677 •'"' tmsl.elbstuf-l6o , ���
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comi)4 State,Variance,etc.) ft. [t. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1?%175CREEN..�t� ''��`' :.•;'1� �.''�I�'�" ����'��a�. �.;��a�,s '��,�.���le;::
lulu y FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) xMResidential Water Supply(single) % ft. Ini
IndustriaVCommercialResiderttial Water Supply(shared) GROi>T
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 [t. 20 tt. BENTENITE POURED 14 BAGS
Monitoring pRecovery
Injection Well:
Aquifer Recharge ©Groundwater Remediation
M.
�M9 SAND/.GR'i1VEL�'PiACIC? f a °ITcatile .;. ;.,
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer
+FZ'0 DRILIiING'tGt)GS'attach adtlldonplish�e'talit`scecesss s � :
FROM TO DESCRIPTION color,hardness;soWrack a rain size etc
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 ft. 100 ft• CLAY
4.Date Well(s)Completed:P Well ID# lot ft. 305 ft, GRANITE
5a.Well Location:
JACOB JACKSON ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
38 GLORY DR.
Physical Address,City,and Zip ft. ft. n')
POLK lli'iREMA1tKS:fiT, e 4. 4t t ??` r as,.l tr� v a s ,;
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:
35.1934819 N -82.1313670 W
6.Is(are)the well(s)E% Permanent or Temporary Signature of Certified Well Contractor 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: QYes or u)No with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain lite nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on tire 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: 305 ([f•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing:40 (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.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Clenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: AIR 24c.For Water SUDDIV&Iniection 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 coup health department of the
13b.Disinfection type: Amount: P n' p county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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