GW1-2022-01109_Well Construction - GW1_20220107

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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 ft. ft.
NC Well Contractor Certification Number 15.OUTER CTSGfor multitased wells ORLNR f Iicable
CAMP'S WELL&PUMP CO., INC. FROM oIN DIAMETER TH
MATERIAL
0 ft. 160 ft 6.125 1" SDR21 PVC
Company Name
EH22775 16.INNER CASING OR TUBING` eothermal closed-too
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MAT MAL
List all applicable well construction permits(i.e.UIC,County,Stale,Valiance,etc.) ft ft. in.
3.Well Use(check well use): ft. tn.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaMblic rt. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g. ft. In.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 20 it• BENTENITE POURED 14 BAGS
Monitoring EIRecovery
Injection Well: ft. it.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK Na licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
_ Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatingtCooling Return) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness sowroek type,prains etc
0 ft. 160 iL CLAY
4.Date Well(s)Completed: _ Well ID# 161 ft- 405 ft. GRANITE
ft. rt
5a.Well Location: -
DIANNA PAINTER rt. ft. q
Facility/Owner Name Facility ID#(if applicable) ft. ft.
151 PAINTER RD. 1.4
Physical Address,City,and Zip ft. ft. o, ?'
POLK 21.REMARKS
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.Ce ation:
35.325771 N -82.143549 W
6.Is(are)the well(s)OPermanent or"OTemporary Signature of Certified Well Con ct r Date
By signing this form,1 hereby cert fy that the rvell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 ofthis 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 (it-) 24s. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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 ofjthis 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
13s.Yield(gpm) 3 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.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016