GW1-2022-01441_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGE17 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
k,
4545-A
n. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mnititased wells OR LINER f a ll I
CAMP'S WELL& PUMP CO., INC. FROM TO DIAMETER THICKNESS MATERIAL
0 it- 42 it- 6.125 'a' I SDR21 PVC
Company Name
BURKE CO. - NO PERMIT 16. AM eothermalclICKN S
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft
3.Well Use(check well use): rt. ft. 4 in.
Water Supply FR Well: FR SCREEN l
OM TO 'DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural D /Pu Municipalblic ft. IL Ip•
Geothermal(Reating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaVCommercial Residential Water Supply(shared) 18.GROUT_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f'' 20 f'' BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage IL
Experimental Technology OSubsidence Control tt• tL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks 0 4 F T DESCRIPTION color,haran soiUrock a rain size,etc:
0 [t. 2 fL CLAY
4.Date Well(s)Completed: Well ID# 43 ft. 405 ft. GRANITE
tt. ft.
5a.Well Location:
ft. fL '� ,�zu
JEFFERY PYATT x-a, �- u
Facility/Owner Name Facility ID#(if applicable) ft. IL }
6442 DYSARTSVILLE RD. rt. rt.
,..:
Physical Address,City,and Zip ft. ft.
BURKE 21.REMARKS
Lill Jib
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:
35.632665 -81.841947
N _ W
Signature Date
6.Is(are)the well(s) Permanent or Temporary of Certified Well Contractor
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []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 this record has been provided!o the well owner.
repair under#21 remarks section m•on the back of this forni. 23.Site diagram or additional Jell.details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 lfdifjerent(example-3®200'and 2©1001 construction to the following:
10.Static water level below top of casing:60 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service f enter,Raleigh,NC 276994617
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) 2 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 I the county health department of the county
where constructed. IIIf
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016