GW1-2022-03209_Well Construction - GW1_20220308

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A
k, ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Ilcable
CAMP'S WELL& PUMP CO., INC. FROM TO DIAMETER THICKNESS MATERIAL
0 it,. 138 ft- 6.125 � In' SDR21 PVC
Company Name
13487 16.INNER CASING OR TUBING geothermal closed-too
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT I
hTl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• BENTENITE POURED 14 BAGS
Monitoring _ Recovery 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 k. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiVrack a rain a etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
J/► 0 ft. 138 ft- CLAY
4.Date Well(s)Completed �/'z Well ID# 139 fi• 225 fi' GRANITE
ft. ft.
5a.Well Location:
MICHAEL ODOM ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
1668 SAINT MARKS CHURCH RD. k. ft.
Physical Address,City,and Zip ft. ft.
GASTON 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.Certification:
35.395398 N -81.312173 W /l
6.Is(are)the well(s)oX Permanent or ❑ITemporary Signature of Certified Well Contracto 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 )No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill oul!mown 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: 225 (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 1Q1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
#'water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.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 o'f 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) 20 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
136.Disinfection type: Amount: P tY P
where constructed.
Form GW-I North Carolina Department ofEnviroomental Quality-Division of Water Resources Revised 2-22-2016