GW1-2022-06943_Well Construction - GW1_20220601

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ALL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 9142 WATEWZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A ft. ft.
NC Well Contractor Certification Number 0S'OUTER=G`ASING!f iiIti k ceseiWi!! 1INER'ifis"`dca"tilenti
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 it- 42 ft- 6.125 1" SDR21 PVC
Company Name ,u w �: t�
.SW20-021 7 �,y16.,INNERICASING;OItTUBING;`eottiermiilirlosed=to"ti' a��,�� �. .�,;t,=
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. et. in.
3.Well Use(check well use): ft. ft. in.
W4SCREEN7:ru+`7 r'S..iC''x,.'F"Lidfl'-,;
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) In.
Industrial/Commercial []Residential Water Supply(shared) [r18:aGROUT' ?0
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 tt. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Q Stormwater Drainage
Experimental Technology []Subsidence Control it. et.
Geothermal(Closed Loop) []Tracer ,;t=--DR1liI:ING'LUGi itittech.iiddttioiial.slieets if neces3ii`:".r 1 ,.4* "ti. k;
FROM TO DESCRIPTION color,hardness sottfmck a rain size etc.)
Geothermal(Heating/Coolingg(Return)�j Other(explain under#21 Remarks 0 ft. 42 ft- CLAY
4.Date Well(s)Completed:J S / Well ID# 43 ft' 505 ft' GRANITE
5a.Well Location: ft. ft.
ROB RIVERA
Facility/Owner Name Facility ID#(if applicable) ft. ft.
407 WALLS CHURCH RD. ft. et. ;; 1 2022
Physical Address,City,and Zip ft. ft 4
RUTHERFORD 21:sRENIARKST
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:
35.38173 N -81.78601 W it
6.Is(are)the well(s)EX Permanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the soell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or X®No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repah;fill out known well construction information and explain life nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of thisform. 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 if dierent(example-3@200'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 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) 5 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 to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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