GW1-2022-07225_Well Construction - GW1_20220411

P i t dorm
STRUCTION RECORD GW-1 For Internal Use Only:
tractor Information:
ETT J. PADGETT A4 WATElL%0NES
Contractor Name FROM TO DESCRIPTION
ft. ft,
/NC
5-A
ft, ft.
cII Conhactor Certification Number15 bUTERiGMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 t. 83 ft. 6.125 in• SDP21 PVC
any Name
SW21-0452 16rINNERt?ASING.OR=IIIBING"'cothethisliClOsad-luo" tas �tX�; r '
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well constnrction pennits(i.e.UIC,County,State,variance,etc.) @. ft. in.
3.Well Use(check well use): H. tt. In.
Water Supply Well: 17."SCRELNFy
FROM I TO vI DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural E31vlunicipal/Public fL ft. iu.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) n• fL to.
IndustrialtCommercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: o fL 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Non-Water
Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salini Barrier P-10 ANDIGWAYELI;PXC1C' /a`"li€ ble der
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer F 20ciDRILLINGI 01G attach iidalUo"oaltsfieef'a ltaeceeaa `,'
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sailtrack a rain size etc.
0 ft. 83 ft• CLAY
4.Date Well(s)Completed: 3 q�2_Well ID# 64 ft• 605 ft, GRANITE
5a.Well Location:
ROY KIRK rt. ft. APR 1 1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
138 BILL DECK RD. n. rt. li$, ':Z' :iic: l
Physical Address,City,and Zip ft. ft. �
MCDOWELL ZI iREMARK3 •€ ,r ?r.-' +,r, a e ; :s
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.Ce fication:
35.580577 N -81.841992 W
6.Is(are)the well(s)Ox Permanent or Temporary Signature of Certified Well Cdiftractor Date
By signing this form,/hereby cetfy'that the ivell(s)'was(were)construcied in accordance
7.Is this a repair to an existing well: Yes or EJNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consrnrcrion Standards and that a
Ifthis is a repair,fill out known well consinretion 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-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: 605 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 50 (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) Method of test: AIR 24c.For Water SunDly&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.
Fomt GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016