GW1-2022-01818_Well Construction - GW1_20220218

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 7
GARRETT J. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multt-cased wells OR LINER f a livable
CAMP'S WELL& PUMP CO., INC. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 43 ft. 6A25 tn' I SDR21 PVC
Company Name 16.INNER CASING OR TUBING! eothermal closed-loop)
2.Well Construction Permit#: SW21-0522 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERLIL
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft.R
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft• BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothenmal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size etc.
? ^7 0 ft. 43 fL CLAY
4.Date Well(s)Completed: �4°Z Well ID# 44 ft• 545 ft. GRANITE
5a.Well Location:
STEVE CHAPMAN/VALERIE MO ORE ft. ft. PER 19
Facility/Owner Name Facility ID#(if applicable) ft. ft. `
77 DIXIE DR. ft. ft. 6 *C
ft. tt. tom , P I
Physical Address,City,and Zip
MCDOWELL 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
35.677544 N -81.911477 N,
6.Is(are)the weil(s)oX Permanent or ❑ITemporary 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: DYes or X)No with ISA NCAC 02C.0!00 or ISA NCAC 02C.0200 l•Vcll 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:
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: 545 (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: Y�:'G (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 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: 11
(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) ( 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
CHLORINE 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: Amount: p
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016