GW1-2021-02564_Well Construction - GW1_20211110

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WILL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name g, tt.
4545-A rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for rou1H-cased ells)OR LINER iF a Dcable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 1 43 ft. 1 6.125 ia' I SDR21 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
2.Well Construction Permit#: SW21-0230 FROM TO DIAMETER In.
MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rt. ft io.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural DMunicipal/Public ft. rt. I in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriallCommercial DResidential Water Supply(shared) lg.GROUT
Irrigation - FROM 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 Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage ft ft.
Experimental Technology DSubsidence Control tt. ft.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,herdaess sofUrock e, roia siz etc.
Geothermal(Heating/Cooling Coolie Return)! Other(explain under#21 Remarks 0 h 43 fL CLAY
4.Date Well(s)Completed: ID# 44 ft. 445 R. GRANITE
ft. ft.
5a.Well Location:
COZETTE COATS rt. rt.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. Alaw
121 WB PHILBECK RD. BOSTIC, NC 28018
rt. rt.
Physical Address,City,and Zip
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.383190 N -81.782179 W
6.Is(are)the w.ell(s).OX Permanent or DTemporary
gnature of Ce 'i Well Contructor D to
By signing t 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 15A NCAC 01C.0/00 or/5A 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 welt owner.
repair under#21 remarks section or on the back of this farm. 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: 445 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing:40 (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 Infection 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 Servie4 Center,Raleigh,NC 276994636
13a.Yield(gpm) 20 Method of test: AIR 24c.For Water Sunnlv Bc 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016