GW1-2022-03659_Well Construction - GW1_20220321

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WELL CONSTRUCTION RECORD (GW-1)
1.Well Contractor Information: z 4
GARRETT J. PADGETTs, 2
Well Contractor Name ,r n;
4545—A rt. fL
NC Well Contractor Certification Number
�'15�'OUTERYC�ASIN�:.ftr,,mulff�eased�w""le is iOHtlI:INERd ra"''Itcatile
CAMP'S WELL AND PUMP CO. FROM TO I DIAMETER THICKNESS MATERIAL
0 ft. 125 ft. 6.125 to- SDR21 PVC
.
Company Name lei`fi1R,*ER1GtiSIL]G;UR�nZ�11BINCs9" dtl�er�taL lo" tle (1 '
2.Well Construction Permit#: SW 19-0410 FROM I TO DIAMETER In. THICKNESS MATERIAL
List all applicable well construction permits(I.e.U1C,County State,Variance•etc.)
ft. ft.
t, ft. in.
3.Well Use(check well use):
lv1'1c4SCItEEN.
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural )Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) %)Residential Water Supply(single) ft. ft. in.
Industrial/Commercial )Residential Water Supply(shared) I i8.giGRDU!I?# a � "�'
Irri ation FROM' I TO MATERIAL#I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 20 rt• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge )Groundwater Remediation
?]9e5d191)lGR'Ai1'EL PACIk iVi 'lic-Ab°la "
Aquifer Storage and Recovery )Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test )Stormwater Drainage ft. TO
Experimental Technology )Subsidence Control
Geothermal(Closed Loop) )Tracer 01WRIMMEII9G;Lr0'G$"titta`2 :DESCR P"TION(color,hardness,
FROM TO DESCRIPTION color,hardneaa aoWroek e,grain aize etc
Geothermal(Heating/CoolingReturn Other(explain tinder#21 Remarks) 0 tL 125 rt• CLAY
4.Date Well(s)Completed:` `' Well ID# 126 ft- 300 rc' GRANITE
ft. tt.
5a.Well Location:
ft.KEITH &DIANA BUCHANAN tt.
Facility/Owner Name Facility ID#(if applicable)
98 COBBLESTONE DR. MARION
Physical Address,City,and Zip
MCDOWELL —
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.709524 N —81.954327 W
Signature of Certified Well Contractoi Date
6.Is(are)the well(s)�X Permanent or )Temporary i
By signing this forms,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or JMNo with 15A NCAC 02C.0/00 or ISA NCAC 01C.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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (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 eQt 200'and 2@100) 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
l 1.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) 6 Method of test: AIR 24c.For Water Supply&Infection 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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P�rInt3Fo�m'" ;
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: r
GARRETT J. PADGETT &11M1 WATER+ZONEsn`a? ' 4rq s'.,? f'z t�ufisE,`a�w :a:
FROM TO DESCRIPTION
Well Contractor Name ft. rt.
4545-A a. ft.
NC Well Contractor Certification Number 13:4UUTERIGA$INGI for„muldecasc'dnwe]S TOR$I31NFR lfrsa""Ilcatile
CAMP'S WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft 1 75 ft. 6.125 in. SDR21 PVC
Company Name ""
W21-0048 �16:iINNERCASING,�OR&'1111BINC� eothen�"ianlosed*if'
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc) ft. ft. In.
ft. ft. in.
3.Well Use(check well use):
t=v +
..a s cry�.• ••
� � '._
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. I ft. I In.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft I ft. ia.
Industrial/Commercial QResidential Water Supply(shared) 518 GROUVs4t ?' :i 'v
irrigation
FROM TO MATERIAL EMPLACEMENT:Ed
Non-Water Supply Well: 0 ft. 20 fi BENTENITE POURED 14 BAG
Monitoring Recovery
Injection Well: ft. n,
Aquifer Recharge QGroundwater Remediation :;SANDIGRpL:P.ACK� f's` Ifcfitilc' ., SAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [38tormwater Drainage rt. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer f 201 DRILY I1VG LOG7 ittech aildltliiriel stieetl ltlaecessa`. �4a "�"
FROM TO DESCRIPTION color,hardnesa,soil/rack a rain size,etc
Geothermal eatin Coolin Return) Other(explain under#21 Remarks 0 ft 75 rt• CLAY
4.Date Well(s)Completed: zz Well ID# 76 ft 405 ft. GRANITE
5a.Well Location:
JEFF&SHEILA ETHERIDGE
ft. ^.
Facility/Owner Name Facility ID#(if applicable) CL
573 FREE PATH DR.
Physical Address,City,and Zip ft. it MAR 24 202"
MCDOWELL =i21:'REMARXV1,? • 'c. n
County Parcel Identification No.(PIN) -
l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i,1
(if well field,one lat/Iong is sufficient) 22.Certification:
35.670323 N -81.905247 W
Signature of Certified Well Contractor I Date
6.Is(are)the well(s)M% Permanent or 13Temporary i
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Constuction 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 ojthis 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3Q200'and 2©100� 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 Injection 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,i 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 SUDu1V&Iniee�tion 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016