GW1-2022-03669_Well Construction - GW1_20220321

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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 g. 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& PUMP CO., INC. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 80 It. 6.1251, 1°' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: yv v (� D y FROM To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pennits fl.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in. -
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) rt. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring ORecovery rt. ft.
Injection Well: ft. ft.
Aquifer Recharge �IGroundwater Remediation
19.SAND/GRAVEL PACK is applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothenal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil rock a rain size etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 ft. 80 ft CLAY
4.Date Well(s)Completed:e _x�_ Well ID# 81 tt' P45 ft. GRANITE
ft. ft.
5a.Well Location:
CAROL WALKER et. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. f�
ft.
HOGAN RD./321 JOYCES TRAIL
rt. -�
Physical Address,City,and Zip rt. MAN
RUTHERFORD 21.REMARKS -
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:
35.218629 N -81.869192
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified Well Contrac 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 X)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-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: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3Q200'and 2@1001 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 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.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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 Ito the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources