GW1-2022-01597_Well Construction - GW1_20220204

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRE17 J. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
CAMP'S WELL& PUMP CO., INC. FROM TO DIAMETER T HICKNESS MATERIAL
0 ft• 95 it 6A25 in. SDR21 PVC
Company Name 16.INNER CASING OR TUBING eother al closed400
2.Well Construction Permit#: SW21-0374 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. lin.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
IndustriaYConunercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK U applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness,soiLlrock e, rain siz etc.
Geothermal(Heatin Conlin Return) Other(explain under#21 Remarks)
0 ft. 95 ft• CLAY
4.Date Well(s)Completed: - Well 1D# 96 ft. 245 ft. GRANITE
5a.Well Location: ft.
SHERRY YOUNG
Facility/Owner Name Facility ID#(if applicable) ft. ft.
105 BLUE BIRD MEADOW DR. NEBO ft. ft.
Physical Address,City,and Zip ft. ft. 42027
MCDOWELL 21.REMARKS
County Parcel Identification No.(PIN) n 1.
'14FUL4Wffi
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.655522 N -81.921890 W
6.Is(are)the well(s)�IX Permanent or ❑ITemporary Signature of Certified Well Cont r Date
By signing this form,I hereby certify that the well(s)ivas(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 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 I GW-I 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 if dtfferent(example-3@200'and 1@I001 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) 2 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: 2CUPS completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016