GW1-2022-04146_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT ;Ia;rwnz�ERazoNEsru.:KF .� 4 : :{.:,. .a a ur4r a: a' _° - 5
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A
ft. ft.
NC Well Contractor Certification Number UinERr_@ASING'fur,"multl asedlwells'iOR�T INER''if a"llcaDle E ;
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 170 ft. 6.125 In, SDR21 PVC
Company Name ��
2.Well Construction Permit
�� n��� �161IN1VER<CASINC�URfrTiUBIN(ii' eotheiaieltclose`d=too �t. fr�a.''.'� ",�'s?�'�.•?i`n
#: U FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
17'=SCREEN�;;�h. i$_�i _x.,°,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
t184GROUT41
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
,19i'SAND/GRANENPAC1 ifihbblWable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer ?�20:'DRIILINGrI3UG'iitiectiiudilitinnalahee4iffneees`sa .. .".: '_s A .;wn :1
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.
0 . ft. 170 ft- CLAY
4.Date Well(s)Completed:�7 ZZWell ID# 171 ft- 245 ft- GRANITE
5a.Well Location: ft. ft.
A (e.m rt ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
BITTEROOT CIR. ft. ft. K, �
Physical Address,City,and Zip
ft. ft.
RUTHERFORD _
County Parcel Identification No.(PIN) i 1,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dwell field,one lat/lon is sufficient
(� g� ) 22.Certification:
35.415030 N -81.989838 W
.�-�l-ate
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contracto7j, Date
By signing this form,I hereby certify ghat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or XQNo will,15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the natitre of the copy of this record has been provided to the well owner.
repair tinder#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 if different(eraniple-3@200'and 2@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 Iniection 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) 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
13b.Disinfection type: CHLORINE Amount: 2 CUPS 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 Resources Revised 2-22-2016