GW1-2022-09593_Well Construction - GW1_20221021

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT M:;WAMWZONES9V k:;Mr'4�.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A
ft, ft.
NC Well Contractor Certification Number13i'OU I ER<CASINGt for mlilti?casedlwells bR1IS]NER<N a"_Ilcable '' ``
CAMP'S WELL&PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 90 ft. 6.125 In' SDR21 PVC
Company Name �16i3N1VERt:CASING'iOR`�UBINC' 'eothermsl'blosefl�lbo w v):.
2.Well Construction Permit#: EH22498 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well consamction permits(i.e.UIC,Comity,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft ft io
?4..>�f ".3 �: 'RX
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
In
Well:
Aquifer Recharge OGroundwater Remediation t r top en h ° F
�19s,SAND/GRAVELtPACKtiifa"licablerr. :�...,,,:r`�-r..k..*:� ,t�:x.'.z. �'
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology [3Subsidence Control
i
�, €? '
Geothermal(Closed Loop) Tracer �430iiDRIEVING LOG attach,addttlonal`sli=44lGnecess3 _:' t
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,praln size etc.
0 rt. 90 ft. CLAY
4.Date Well(s)Completed: Well ID# 91 rt' 245 ft GRAN ITE
5a.Well Location: tt. tt. _ °
AUSTIN HALL
Facility/Owner Name Facility ID#(if applicable) n• ft.
COLLINSVIILE RD.WILLA'i RIDGE LN.
Physical Address,City,and Zip ft. ft iRtufrfl 1 t f^C
asono Unit
POLL r:2VOREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
35.20777 N -82.11134 W
6.Is(are)the well(s)E% Permanent or Temporary Signature of Certified Well Contractor Date
By signing diisform,I ltw•ebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or XJNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consd•wction information and erplain the nature of the 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:
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate 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 multipie wells list all depths if di:fferent(example-3 a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above Basing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
F
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) 8 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