GW1-2022-04064_Well Construction - GW1_20220425

' CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
GARRETT J. PADGETT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4545-A
it.
ft.
F .
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NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a llcable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 tt. 65 ft 6.125 1°' SDR21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loon)
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2.Well Construction Permit#: vv ©. `J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
FAquifer
Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
g Recovery ft. ft.
ell: ft. ft.
echarge ❑I Groundwater Remediation 19.SAND/GRAVEL PACK if a licabletorage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑IStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,saittrock e, rain size,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks)
0 ft. 65 ft- CLAY
4.Date Well(s)Completed: Well I D# 66 tt. 605 tt. GRANITE
Sa.Well Location:
ft. ft.
NATHANIEL HANLINE ft. fL
Facility/Owner Name Facility IDk(if applicable) ft. ft.
MCOWENBEN PASS
Physical Address,City,and Zip
ft. ft.
RUTHERFORD 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:
35.409775 N -82.149985 W
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: QYes 'or QX No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction infonnation 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 ofthisforni.
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: 605 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: (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 Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this farm 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 27 69 9-163 6
13a.Yield(gpm) Method of test: AIR 24c.For Water Supply&Iniection Wells: In addition to sending the form to
CHLORINE z cups the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsour Ies Revised 2-22-2016
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