GW1-2022-04164_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT I14:iWA!<ERZONESy, -Vc ,,.%,?
Well Contractor Name FROM TO DESCRIPTION
ft.
4545-A ft.
ft. ft.
NC Well Contractor Certification Number ,i',15.OUTER'�CASDrG'(for:multhcased).*01%OR�LINER''ifia-"licatile' +j.fu;
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
p ft. 110 fI• 6.125 In. SDR21 PVC
Company Name �16JNNER:CASING;UR:TUBINGI jeottiermal dosed=too E s a
2.Well Construction Permit#: 13579 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constntction per i nits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
4173CREE11; a'i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. Ia.
IndustrialiCommercial Residential Water Supply(shared) ;18d,GROUT;
Irri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft• BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
3�79 SAND/GRAVEL;?PACK If.il`,Bcilble fin_?, 4e X'' ?+:�,
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test Stomtwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer �,20i'WRWLING'1,;UG attach;eilditiaual shiets'rf,necigiiii
Geothermal (Heating/Cooling Return) MOther(explain under#21 Remarks)J
FROM I TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
/� ry 0 ft. 110 ft. CLAY
4.Date Wells)Completed: �02 If�{vnWell ID# ill ft. 2e5 ft. GRANITE
5a.Well Location: ft. ft.
THOMAS RAINES ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. fr.
347 EAKER RD.
Physical Address,City,and Zip ft. ft.
)F1'p.
GASTON ZI tREM'ARKSi'a 4iT ,a t z 242'C 1TR ITC o y?,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.332389 N -81.333599 W
6.Is(are)the well(s)MM Permanent or 13Temporary Signature ofCertified Well Contractor 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: -[3Yes -or JNo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Constnnction Standards and that a
Ifthis U a repair fill ottt known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#21 remarks section or on the back oflhisform.
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: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nttdtiple wells list all depths ifeli ferent(example-3@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,
ifwater level is above casing,rise"+" 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: AIR 24c.For Water Suauly&Injection 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: z 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 Watcr Resources Revised 2-22-2016