GW1-2021-07657_Well Construction - GW1_20211215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT ,.14.°WATER ZUNEs„--
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A ft. ft.
NC Well Contractor Certification Number 15 OUTER`GASING for rou1N?ce's`edfweBs OR MAIM °IiEable s ,;S
CAMP S WELL AND PUMP CO.
FROM TO DIAMETER THICKNESS I MATERIAL r
0 ft. 50 ft. 6.125 in. SDR21 PVC
Company Name 1¢ INNER CA3ING,01r-,TU.B11VG' eotheimel
2.Well Construction Permit#: 13528 FROM TO DIAMETER THICKNESS MATERIAL}{
List all applicable well construction permits(71.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt ft in
1 47 SCR-EEN
Water Su
PP Y Well FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal(Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Geothermal
Irrigation FROM TO • 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:€SiTD/GRAWELPACR :a"``licsble r „•.. .3 ¢' < , :: ..
_Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer s20 0R1I.LING.LOG;attacti additional sheets if;nece§sa .:_.
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type, rain size,etc.
0 ft. 50 ft. CLAY
4.Date Well(s)Completed: d Well ID# 51 ft• 245 ft• GRANITE
5a.Well Location:
OAKWOOD HOMES ���G�-1�r6 L�yL.
Facility/Owner Name Facility ID#(if applicable) ft. ft. T:
JACK BRIDGES RD. KINGS MTN. ��y
Physical Address,City,and Zip ft. ft. nFr1 5
GASTON
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:
35.297652 N -81.337891 W
6.Is(are)the well(s)OPermanent or ©ITemporary Si ature of Ce Well Contractor Date
By signing[ is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of[his 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 multiple wells list all depths If different(example-3(a)200'and 2Q100� 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 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) 5 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016