GW1-2022-04864_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information:
GARRETT J. PADGETT
,,14'•�WAT"E1t,20NES ,1-.?� .1..,.>...�,���t_ax
FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
4545-A ft. fL
NC Well Contractor Certification Number ,15 UiJTERt iTSINGf foi'multl=cased4ivells URtL'INER ff:a""llcatile .:'._ �
CAM P'S WELL & PUMP C O. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 55 ft 6.125 In. SDR21 JPVC
Company Name �+ :r16::INNERG`ASIN_G'OR'TtiBINCyi cotlie'rinel!eiosed=too qr fix. rt .. xu z i
2.Well Construction Permit#: SW21-0102 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc.) ft. ft. in.
ft 3.Well Use(check well use): ft In
i',17",$CREENS'',5.'s �i�.'c,.!.".i._..3.ri:.4�s,:rhr .,rv;'1..:%�T.�r}w,'•3 .. �•i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. I in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) g,r18 GROIJT . �v.; i +ri rrlf.i Put;r •sr xs. •' m.r'. r.;-'
❑Irri ation ❑Wells>100,000 GPD FROM TO I MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 rt BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation !.
1A51SAND%OI:4VEli�PAISK f e"'lleable rl;,,.,_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control ft. ft.
[]Geothermal(Closed Loop) ❑Tracer 4�10;fDWU-7INGJV6 attach;additihoeli'S&itsiiftnecessa""`
FROM TO DESCRIPTION color,hardness soil/rock a rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 55 ft. CLAY
4.Date Well(s)Completed: r�Well ID# 56 ft• 1305 ft. GRANITE _
5a.Well Location:
PETER GAULIN f`' ft'
MAY 0 r'" =
Facility/Owner Name Facility iD#(if applicable)
rt. ft.
Fac
HOLLIS RD. ft. ft.
ft. ft
Physical Address,City,and Zip
RUTHERFORD
�.- :! r_,t 1xs.Z,.earb.4- ._tf,.. e_cr4.«,,�3�.•h�,:'+?r `,-�'>3"r"'�ti:..:„A. ..Srf.
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:
35.406843 N -81.738864 W S adz
6.Is(are)the well(s): IJPermanent or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or . InNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!'this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (fL) Submit this GV1W-1 within 30 days of well completion per the following:
For multiple wells list all depths ifili Brent(exam aple-3 200'and 2 u+1001
24a. For All Wells: Original Form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY 24c.For Water Su I and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments tea epartment o the county wliere insta7fe
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7 Method of test:A I-►R '
13b.Disinfection type: CHLORINE Amount: 2 CUPS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018