GW1-2021-00241_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Well Contractor Information: j
GARRETT J. PADGETT 1a.xwATERzoNEs, _; .. x_,x h. .
We1lContractorName FROM TO DESCRIPTION ft. ft.
4545-A
fa ft.
NC Well Contractor Certification Number
15%OUTER'?CASING fotPulN:et"sed wells OR l INE[t, i''Ileable`.,
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft' 90 ft' 6.1251 in. SDR21 PVC
Company Name 16 INNER;CASING Oft=�UBING "eotherm_ ill blosedeloo
2.Well Construction Permit#: SW20-0526 FROM TO DIAMETER THICKNESS MATERIAL I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
1 e : 17SCREEN
Water Su
pp y Well: FROM TO DIAMETER SLOT SIZE Y,THICKNESS MATERIAL s
Agricultural [3Municipal/Public rt. tt. in.
:]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, rL n•
IndustriallCommercial Residential Water Supply(shared)
18.:GROi1TI N'.
_ hTi ation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring QRecovery 17L ft.
Injection Well:
ft. tt.
Aquifer Recharge DGroundwater Remediation
10:SAND/GR?YE1 PACK rf,a 1c'able n niy . z Y.. '
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20;DRILLING'<1 OG:atte`ch.iidditioual sheet`saf riecesse';.
Geothermal(HeatingtCooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sailtrock type,
rain si etc.
0 ft. 90 ft, CLAY'
4.Date Well(s)Completed: - Well ID# 91 ft. 405 ft* GRANITE
ft. ft.
59.Well Location:
JIM &TERESA LANDON
Facility/Owner Name Facility ID#(if applicable)
50 FALL CK. DR. VEC I
Physical Address,City,and Zip
MCDOWELL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.556198 N -81.892109 W
6.Is(are)the well(s)OPermanent or Temporary Signature Pf Certifi d Well a Date
By sig>ling this form I he eby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or E)No Wi 6.15A NCAC 02C. 1 0 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 oft py of this record has een 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2@1001 construction to the following;
10.Static water level below top of casing: 240 (ft.) ® Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mail Service(Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection 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.) f
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: AIR 24c.For Water SDDDIV&Inie Ition 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 Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016