GW1-2022-00937_Well Construction - GW1_20220107

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STRUCTION RECORD GW-1 For Internal Use Only:
or Information:
. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
me ft. ft.
rut. rut.
r Certification Number 15.OUTER CASING for multi-cased wells OR LINER a Iicable
FROM TO DIAMETER
CAMP'S WELL AND PUMP CO. THICKNEss MATERIAL
0 ft. 84 ft, 6.125 In' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
TO DIAMETER THICKNESS MATERIAL
SW21-0339 FROM
2.Well Construction Permit#: fa IL in.
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) in.
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water
cultural []Municipal/Public R• ft. run.
Geothermal(Heating/Cooling Supply)
Residential Water Supply(single) R, ft.
to.
Industrial/Comirtercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lrri ation 0 ft. 20 fi• BENTENITE POURED 14 BAGS
Non-Water Supply-fell:
Monitoring
Recovery ft. ft.
Injection Well: ft. tt.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
t1�--II,SSlini Barrie[ FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Storage and Recovery 1� ty ft. fL
Aquifer Test DStormwater Drainage
Experimental Technology
�1 Subsidence Control ft' ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets o hardness
FROM TO DESCRIPTION color bardaeu solUrock rain a etc.
Geothermal eatin Coolin Return) Other(explain under#21 Remarks 0 it. 84 fL CLAY'
-'�, w¢u ID# 85 ft. 505 ft. GRANITE
4.Date Well(s)Completed: t V:l
5a.Well Location: qt, ft.
TRISTON EDGERTON rut ft.
Facility/Owner Name Facility ID#(if applicable)
MATTHEW CHURCH RD. ft rut. I;
Physical Address,City,and Zip 21.REMARKS
RUTHERFORD
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
35.400531 N -82.072170 W )y
nature of C ell Contractor Date
6.Is(are)the well(s)oX Permanent or oTemporary
By signing jonn,I hereby certify that the well(s)was(were)constructed r accordance
7.Is this a repair to an existing well: Yes or X@No
with 15A AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the
copy of this record has been provided to the tivell owner.
repair under#21 remarks section or o»the back ojthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Cl osed-Loop You may use the back of this page to provide additional well site details or well
Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit(this form within 30 days of completion of well
For multiple wells list all depths tjdt ferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Method of test: AIR 24c.For Water Supply&Injection Wells: lira addition to sending the fats to
13a.Yield(gpm) 4 the address(es) above, also submit one copy of this form within 30 days of
Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: CHLORINE where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016