GW1-2021-07070_Well Construction - GW1_20211129

P i o�rn
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT ?�40,WATEMZONCS
FROM I TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A ft. ft.
NC Well Contractor Certification Number
rr"IS:iQUJfER:6i1SINGi foe�maltl-ciiied=_wells;UR�LbNER If?h l(cratile'� ��`���-:
CAMP'S WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft- 55 ft. 6.125 In. SDR21 PVC
Company Name
EH21-02003 ,,1`6:INNER''=.CASINGjUR`s'PUBING? eoiheTmel?dosedjlo"""o' �+
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.U1C,County,State,Variance,etc.) ft. rt. In.
3.Well Use(check well use): ft tt In
17:gCREENzrt;`�, ;. s �s
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural [3MunicipaWublic ft. ft. In.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft.
rt. in.
Industrial/Cornmercial OResidential Water Supply(shared)
Irri ation FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft' BENTENITE POURED 14 BAGS
Monitoring ORecovery ft. tt.
Injection Well: ft. rt.
Aquifer Recharge Qi Groundwater Remediation _.
410S ND%GRAVEL tAGK3_ fia`"Usable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) OTracer 20,DRIL-L'1NGIAG%'sttiichsddltlori`al aheeteaftecessni`"'• T -.E" {_
FROM I TO DESCRIPTION color,hardness soillrock tM grains etc.
Geothermal(Heating/Cooling/Return)
O�ther(explain under#21 Remarks) 0 ft. 55 ft Cuy
/
4.Date.Well(s)Completed: G �l 1 ��i WellID# 56 ft 405 ft' GRANITE
5a.Well Location:
CATHERINE SIMS
Facility/Owner Name Facility IDN(if applicable) ft. ft.
CANKER RD.
Physical Address,City,and Zip ft ft I I t 1i fit Jul �u ,Ui II I
LINCOLN z1REMaRIts: r .t�
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:
35.560044 N -81.334417 W, j _
6.Is(are)the well(s)OPermanent or Temporary signature of Certlasbeen
Contractor Dare
By signing this fby cert jl that the weil(s)was(tivere)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 1SA NCAC or 15A NCAC 01C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature ojthe copy ojthis recorprovided to the well owner.
repair under 021,rcmarla section or on the back ojthis 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3Q200'and 2@1001 construction to the following:
4
10.Statle water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing.use^+ 1617 Mall 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) 3 Method of test: AIR 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
136.Disinfection type: where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016