GW1-2022-08628_Well Construction - GW1_20220906

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CONSTRUCTION RECORD GW-1 For Internal Use Only:
ell Contractor Information:
XX. GARRETT J. PADGETT
_ :,i14;tWWATER'-ZONES
FROM TO DESCRIPTION
Well Contractor Name % I ft.
4545-A ft. ft.
NC Well Contractor Certification Number , 1• t
15;:UUfiERCASING forsmtilti:c'asedtwcU's;OR.LINIi1R f:a''1loatile c
CAMP'S WELL&PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft- 1 115 ft. 6.125 in, SDR21 PVC
Company Name 0'6.4NNER%CASING ORTUBffiGy; entliei mai=closed loo ? F b :`�'n .s +
2.Well Construction Permit#: 31606 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft.
IndustriaVCommercial 13Residential Water Supply(shared) Cg8,.Gs�ROI1T
Irri ation— __ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ff• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer RechargeGroundwater Remediation
ii 19 SAND/GRAYELvPACKi if'a
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer t'20;,DRIL'LINaEOG"dttecL.addiHouel[stieef931fnecessa"
FROM TO DESCRIPTION color,hardness salVrvck .,type,grain 91ze etc
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks
0 ft. 115 ft- CLAY
4.Date Well(s)Completed: 'Well ID# 116 ft. 245 ft, GRANITE
5a.Well Location:
BEN REESE �6.>.. "Id
Facility/Owner Name Facility ID#(if applicable)
710 SUNNYSIDE SHADY REST RD., KINGS MTN.
Physical Address,City,and Zip
i:21':REMARIfS ' .:ar , ..? `'};^-?t_.:• �2��:-�.-� . ...v;r ..'.:�I.,.4 7;�.'
GASTON _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
3 -81.35381
5.31747 N
W
6.Is(are)thewell(s)0Permanent or Temporary
__ _Signature of Certified Well Contractor _ _ Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or xQNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair•fill oat known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop+Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicattr TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (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 r@200'and 2@100) Construction to the following:
10..Static water level below top of casinge 40 (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 Injection 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) 6 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.
Four GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016