GW1-2022-10726_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT MuNw.al>E im
FROM TO DESCRIPTION
Well Contractor Name ft. ft,
4545-A
NC Well Contractor Certification Number 1SSOUTERiGdSING(forlmulti easeifLweBB ORtL"1NERg if:a" licatile "all
CAMP'S WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft- 1 110 ft- 6.125 In. SDR21 PVC
Company Name 616*INNERWASINGO*OtUBING 'eo c't�mdlta6ti'd=1d'o
2.Well Construction Permit#•W22-0167 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well conduction permits(i.e.UIC,County,State,Variance,etc.) ft• fL In,
tL ft. in.
3.Well Use(check well use):
017?SCREEN I '
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL -
Agricultural QMunicipal/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) fta ft,
Industrial/Commercial Residential Water Supply(shared) t(18s'GRODTal � 1 _'iss. ` �..••. )6 `
Irri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation ;;19;iSAND/GRAYEusEAGK•.
Aquifer Storage and Recovery 13salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft• ft.
Experimental Technology > Subsidence Control
Geothermal(Closed Loop) QTracer ;u20PoDRIG1i1VG)LrOG;attachtad'dlitdnalbheets:lfinecessa _,_._- s.:.: s
FROM TO DESCRIPTION color,hardness sollfrock a ratn size etc
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks 0 ft. 110 ft. CLAY
4.Date Well(s)Completed: ����' °LWe11 ID# 111 ft- 605 ft' GRANITE
tt. ft.
5a.Well Location:
RICHARD&SHANNON MAURO tt. ft. fE7 j'�,_. P 7-
ft. tt. s:m .,,.>7 V 3
Facility/Owner Name Facility lD#(if applicable) fl
240 MIDNIGHT PASS e. ft. DEC
rt. rt.
Physical Address,City,and Zip
t21;REMitiRKS' Af
RUTHERFORD
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one tat/long is sufficient) 22.Certification:
35.41894 -82.00053
yu& -- I
6.Is(are)the well(s)�X Permanent or Temporary
Signature of off Certified Well Contractor Dater
By signing this farm,I hereby cer•th•that the well(s)was(were)consirncted in accordance
7.Is this a repair to an existing well: DYes or E)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Constntction Standards and that a
If this is a repair,fill out known well construction 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:
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-1 is needed: Indicate TOTAL NUMBER of wells
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 mndtiple wells list all depths i t diiffer•ernt(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing:^ (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 Suouly&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.