GW1-2022-04165_Well Construction - GW1_20220425

FRI
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETTaERzoNEs =F.:a ¢<ws .., . K' .f <
wAm E
FROM TO DESCRIPTION
Well Contractor Name
ft. tt.
4545-A rt. &
NC Well Contractor Certification Number IrrA OU0�7RiGASING'fog multi psed i@ells UIl IiIN)Rd Ifs' Iicflblb
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. 90 ft. 6A2.5 In. SDR21 PVC
Company Name 16Il�TNER'.CA3ING'OR:TUBIN(''r? reothe'tmoUclosed=too o ?.:s4 �k,.,'.; � ?
2.Well Construction Permit#• 13542 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIC,County,State,Variance,etc.) ft. tt. in.
3.Well Use(check well use): ft. tt in
�_+17SCRC'.EN!✓.+,->''`f���'.M�:.�,�xkF�',i.,rw.43�o_.?
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation .RFROMITO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 20 ft. BENTENITE POURED14BAGSMonitoring RecoveryInjection Well:Aquifer Recharge Groundwater Remediation
RAVETitPAQIC ,e,`livable i�`;'.v�`��sS�,�?�"`:F•�r i'f2'_.?y'ti ''-.".:.���tiw.l ��=--:
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrnwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer I:i26 DRILL'INail;OG'ittach:sd'dltl"onalah`eetsit.necess'a`
FROM TO DESCRIPTION color,hardness,sollfrock e, rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) 0 ft. 90 ft. CLAY
4.Date Well(s)Completed: 1�Well ID# 91 ft. 370 ft, GRANITE
ft. tt.
5a.Well Location:
AARON ARCHIBALD ft. ft. ra rii�N;;AFt-n
t .r- ,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
990 MARY'S GROVE RD. CHERRYVILLE ft. APR 2 J 7022
Physical Address.City,and Zip ft. ft
GASTON ;til>REIGIA'ItIC3�."R3.+ .� i.4"a ry:u•� c° i;fix. `I".,'t''I �' `tr,`', -'
t;.,h
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:35.356964 N -81.380624 W ���J��f✓� ..,,n�o ✓p- "�
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6.Is(are)the well(s)o% Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certipy that the we (s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or %QNo with ISA NCAC 02C.0100 or 15A PICAC 02C.0200 Well Constnuction Standards and that a
If this is a repair,fill out known well construction information and explain Ilse nature ofthe 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 370 (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@200'and 2@100) ConstrtlCtioIt to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: AIR 24c.For Water Simply&Injection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016