GW1-2022-06190_Well Construction - GW1_20220620

t �xRrlrjt�Form�=?
WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT _ s la wnTER=zorlEs r ti ..� t ' >_:f , ' 'f. <`. ..•na4 # .rY<
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A
NC Well Contractor Certification Number 15.1 OU.'PER'VASING for'mu1H ee led tvelle OR=LINER:1f "Itciitile�a b ;
CAMP'S WELL AND PUMP CO. FROM I To DIAMETER THICKNESS MATERIAL
0 ft. 170 ft. 6.125 in. SDR21 PVC
Company Name `16:"DINNER CASINGiUTt:TUB1NCvs eottiemel"closed=too f*:r ?s ri, 'tXr.
2.Well Construction Permit#: SW22-0054 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conduction penults Cl.e.UIC,County, .)State,Variance,etc ft. ft. In.
ft.
3.Well Use(check well use): ft. in.
:17:SCREENca`ti .T _
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft• ft.
Industrial/Commercial Residential Water Supply(shared) 18:GROUTtic
Irrt ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
1-19.�SAND/G VPXCK4060011166161,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stomiwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer t 20 DRII Ii1NG>L'OGr attacti;eHiiltl6nal'elieetsiif necessa• t f":_.,_r.z->- -
FROM TO DESCRIPTION color,hardness,soll/rock a rain size etc
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 0 ft• 170 ft• CLAY
4.Date Well(s)Completed: Well ID# 171 ft 405 ft GRANITE _
Sa.Well Location:
KARLI HOYLE&DYLAN FORD
Facility/OwnerName Facility ID#(ifapplicable) ft. ft. 2 L 20
22
186 CORRY LN., BOSTIC ft. rt. In;cr:r:'i-.I
Physical Address,City,and Zip
RUTHERFORD 114VREMARKS"u
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:
35.44684 N -81.83853 W
"'Lei L
6.Is(are)the well(s)OX Permanent or Temporary Signature ofCcrtified Well Contractor (�— Date
By signing this form,I hereby certify that lire well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or X©No with 15A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Constnnction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair trader#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: 405 (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 uQ+200'and 2(Q100� construction to the following:
10.Static water level below top of casing:60 (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) 2 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: completion letion 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