GW1-2021-07655_Well Construction - GW1_20211215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for mu1H-cased wells OR LINER its ![cable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 45 IL 1 6.125 in. SDR21 PVC
Company Name
25679 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R• ft. In.
3.Well Use(check well use): ft. ft.17.
Water Supply Well: FROM SCREENTo DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. (in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k• 20 It• BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:. ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
RGeothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRiFTI0N color,hardness,soil/rack type,grain size etc.
I �jJt 0 ft. 45 ft. CLAY
4.Date Well(s)Completed: 1 6 i Well ID# 46 ft' 105 ft' GRANITE
ft. ft.
5a.Well Location: e+..
TYLERGREENE +N6, f p
Facility/Owner Name Facility ID#(if applicable) ft. It.
DEC 1
2024 GLASS RD. ft. ft.
Physical Address,City,and Zip ft, ft. WIR SEWN
CALDWELL 21.REMARKS INFORMATInki PVrrrqqW,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 2 .Certificati
35.942568 N -81.643895 W
6.Is(are)the weil(s)oX Permanent or DTemporary atu o i Contractor Date
By s in thi'form hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A N' C 01 .0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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:
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-1 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: 105 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdifferent(example-3 a@200'and 2@1001 construction to the following:
10.Static water level below top of casing:20 (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 Inlection 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) 20 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
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016