GW1-2022-01596_Well Construction - GW1_20220204

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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
ft. ft.
4545-A
rt. tt. G
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
CAMP'S WELL& PUMP CO., INC. FROM TO DIAMETER THICK MESS MATERIAL
0 ft. 75 ft- 5.125 in' SDR21 PVC
Company Name
SW21-0375 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.R in•
Industrial/Commercial DResidential Water Supply(shared) TS.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff. PO ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. I ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soi0rock rain size etc.
0 ft- 75 ft- CLAY
4.Date Well(s)Completed: - -a.�WeB 1D# 76 rt' 245 rt GRANITE
ft. ft.
5a.Well Location:
LYNN REYNOLDS rt. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
75 BLUE BIRD MEADOW DR. NEBO ft. ft.
Physical Address,City,and Zip ft. ft.
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.Cer'fication:
35.655522 N -81.921890 W /
6.Is(are)the well(s)oX Permanent or DTemporary Signature of Certified Well Contractor 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 E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.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 retard 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:
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: 245 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing:60 (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) 4 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
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