GW1-2022-01543_Well Construction - GW1_20220120

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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 DESCRD''rION
Well Contractor Name
ft. ft.
4545-A
e. ft.
NC Well Contractor Certification Number 15.OUTER CASING for TRIO sed wells OR LINER a licable
CAMP'S WELL&PUMP CO., INC. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 135 ft. 6.125 In. SDR21 PVC
Company Name
16.INNER CASING'OR TUBING(geothermal dosed-too
2.Well Construction Permit#•SW20-0225 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it• ft. in.
3.Well Use(check well use): tt. ft.
Water Su 17.SCREEN
PP1Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural j3Municipal/Public ft. ft. io.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it. ft_
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
JInNon-Water Supply Well: 0 ft. 20____ f---BENTENITE POURED':BAGS
Monitoring Recovery ft. ft.fection Well:: ft. tt.
Aquifer Recharge Groundwater Remediation19.SAND/GRAVEL PACK if a llcable -Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)StormwaterDrainage ft. ft.
Experimental Technology Ej Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,eoiurock in 5 etc.)
0 ft. 135 ft. CLAY
4.Date Well(s)Completed: lD-.22, Well ID# 136 ft- 605 ft- GRANITE
5a.Well Location: "•�$" xr"'-
DAVID HOULE ft. ft.
a
Facility/Owner Name Facility ID#(if applicable) ft. & �^
L
64 TABLE ROCK RD. rt. %
Physical Address,City,and Zip ft. ft. -,_:i '3i c'''.t a;.inti
MCDOWELL 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.Certification:
35.706176 N -82.004576 W
l-
6.Is(are)the well(s)OPermanent or 13Temporary Signature of Certified e 1 Conhacyf Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EjNo with 15A NCAC 01C.0100 a•15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis 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 of this form.
23.Site diagram or additional well details:
9.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 i 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: 605 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2 1001 construction to the following:
10.Static water level below top of casing:80 (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) 2 Method of test: AIR 24c.For Water Sunaly&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.
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016