GW1-2022-04855_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
6`
1.Well Contractor Information:
GARRETT J. PADGETT �7a
FROM TO DESCRIPTION
Well Contractor Name
ft, ft. ,
4545-A
rt. rt.
NC Well Contractor Certification Number1$ OI)7tER'CASING for multlr eavedhwells_OR:LINDRa t ta,,liCab10 rsa�;i ik.z *�rt�'i
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 rt 102 ft 6.125 us. SDR21 PVC
Company Name 16'INNRW0ASWG'i s SING eotber nialYelosed"=loo . 37=c.�
2.Well Construction Permit#: SW21-0316 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Counga State,Variance,etc.) rt. ft. in.
3.Well Use(check well use): ft. ft in.
W 1 17 SCREENx3�
ater Su
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal(Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
.,181`�GRO.UT��,. _r_.0�.;•n..r__,c-�.� r.�.e��. ..u,,,��, :n:.� �t�s;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring 13Rccovery
Injection Well:
Aquifer Recharge EJ Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer w20:iDRILVING LOGt attach'lad"dltlondlrslieeta,ifhecea`s"a l fh# s :{13 %s
Geothermal Heatin ooling Return) MOther explain under#21 Remarks) I
FROM TO DESCRIPTION color,kardness seiVrock type,grain size etc.
0 ft 102 ft CLAY
4.Date Well(s)Completed: � Well ID# 103 ft• 505 ft. GRANITE
5a.Well Location: ft. ft. 1 € • p I—I )
DAVID LUECK/POWELL GROUP rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
580 GRANDVIEW PEAKS DR. ft. ft.
Physical Address,City,and Zip ft. ft
MCDOWELL 2UkREMARKS--%M,.:
County Parcel Identification'No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
35.56500 N -81.89563 W
6.Is(are)•the well(s)OX Permanent or OTemporary Sig afore of Certified Well Contractor Date
By signing this form,I hereby cerii/y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If ids 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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 construction 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 Infection 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) 3 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
P
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