GW1-2022-09178_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETTJ. PADGETT y'luWATERtIA'll�l0
FROM TO I DESCRIPTION
Well Co�tr�tor Name
�— ft. ft.
4545-A
4
NC Well Contractor Certification Number ;-15 OUTEk{CASING'for inul8xdasedwells 7.0Bi111NER W "UEktile"
CAMP'S WELL&PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
ti ft • 100 ft• 612.5 i° SDR21 PVC
Company Name I y -
`A/ran r� •167TNNER+EASINGOR'iTUBING, ebthermsl�closei1=15o''
2.Well Construction Permit#: V V LL-O 1 L6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. Ct. in.
ft ft 3.Well Use(check well use): in
17:SCREENr t ': `,• 't :;. wN.`
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public tt. ft. in
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18trGR0UT i.,
—Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft, BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge []Groundwater Remediation
t19�SANDl.G PACK'ifxa Ileallile�` '`"
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20 DRILLING%'0.G attii6his tliilonelshee
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM T DESCRIPTION color,hardness,aolVrock a rain size,etc.
0 ft. 100 ft. CLAY
4.Date Well(s)Completed: Well ID# 101 ft. 165 ft. GRANITE
5a.Well Location:
PATRICK HANCOCK ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. _. i 2022
709 HINES RD. rt. n. _._r ••: t,r�. _,..;,, Ina
Physical Address,City,and Zip ft ft
RUTHERFORD
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:
35.20200 N -81.82060 WAZ v 5 0 z
6.Is(are)the well(s)Ex Permanent or OTemporary Sngnaturc of Certified Well Comractor Date a�
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or qNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill au known well construction information and arplain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#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 I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 165 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,(jerent(example-3Q200'mad 2@1001 construction to the following:
10.Static water level below top of casing:4'0 (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 lnjection 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) 50 Method of test: AIR 24c.For Water Supply&Iniect'ion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE 2 CUPS completion of well construction to
con
13b.Disinfection type: Amount: P the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016