GW1-2021-02597_Well Construction - GW1_20211110

t Prl;t Form
10' WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14 WATE1t;zoNEs H .; ;
Well Contractor Name FROM I TO I DESCRIPTION
ft. ft.
4545-A
rt. rt.
NC Well Contractor Certification Number
IS s'.OUTER?GA5IN�fotY ItPcaseil wells O.R°1�INI+R"=.(1'f`a Ilcatiie�X � $
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 100 ft- 6125 In SDR21 PVC
W21-0504 F016 1NNER'CASINZi"ORxTUBl7VG,"Qthermal"clo"sad liio .- °? n
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well:
17f'9GREEN z
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft.
IndustriaVCommercial Residential Water Supply(shared)
_ :'Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. BENTENITE POURED 14 BAGS
Monitoring I Recovery
Injection Well:
tt. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• ft•
Experimental Technology OSubsidence Control ft. R.
r.
;Geothermal(Closed Loop) Tracer 20;-I)RILEINGG6G'sittach.addltl5ni15heetaifsneceasa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne sollfrock type,prafn size,etc.
qq o e. 100 ft• CLAY
4.Date Well(s)Completed: Well ID# lot ft. 245 ft. GRANITE
Sa.Well Location:
ft. ft.
CAULDER/MCBRAYER LAND CO.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
111 OAK HAVEN TRAIL
Physical Address,City,and Zip ft. ft. 1 ,0
21
RUTHERFORD 4r REMARKS x .�/.��T�/�� ,z
County Parcel Identification No.(PIN) � �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fattlong is sufficient) 22.Certification:
35.417283 N -82.107650 `,lr _
6.Is(are)the well(s)oPermanent or Temporary Si of Certified II C ctor Date
By signing this for ereby certify that the tvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 0 C.0100 or ISA NCAC 01C.0100 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 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 ifdderent(example-3Q100'and 1®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 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: AIR 24c.For Water SuuDly&Injection Wells: In addition to sending the form to
the address(es) above, also subtnit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction t' the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016