GW1-2022-04851_Well Construction - GW1_20220520

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT ;14:WATERIZONES u ,,i=: zs>:;t- ...>�:^: s
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A ft. rt.
NC Well Contractor Certification Number ,15 OUTE&CASING:for riiulti eese8;wells'.OR�IsINER?if_a'µllciitile
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 6.125 in. SDR21 PVC
Company Name fr6t INNERrCA$INGfOR'TUBINi WIter'msl c died=lob TR "'aVt r-t r fz L z_r
SW21-0119 I '
2.Well Construction Permit#' FFROM
TO DIAMETER THICKNESS MATERIAL
List all applicable well constiectionperntits ri.e.UIC,County,State,Variance,etc.) in.
in.
3.Well Use(check well use): EN.-.4:,�Water Supply Well: TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. In•
Geothermal(Heating/Cooling Supply) x[)Residential Water Supply(single) tt. In.
Industrial/Commercial [)Residential Water Supply(shared) T .< n...k ;- fIrri ation 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 Groundwater Remediation
..19.,SAND/GRAVEI;TACK ifs-7ldtible F ;v`I : .5 . ` _M .>•r +s :<
Aquifer Storage and Recovery [)Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage
Experimental Technology [)Subsidence Control It. tt.
Geothermal(Closed Loop) [)Tracer �'',20 DRWLINGaLOGi Atteeh.sdditloniil.sheetsifnecesse':5 fr
FROM TO DESCRIPTION(color,hardness,solUrock a rain size,etc
Geothermal eatin Coolin Return) Other(explain under#21 Remarks) 0 ft. 70 ft. CLAY
4.Date Well(s)Completed: —pZ2 Well ID# 71 ft 345 ft, GRANITE
5a,Well Location:
JERRY&KARA DOTSON
Facility/Owner Name Facility ID#(if applicable)
262 LITTLE GARDEN WAY ft. rt. MAY 2 __
ft. ft.
Physical Address,City,and Zip
MCDOWELL
21:+REMA'EtIfS..�. ..+,.. r,- .3 _ �•*`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35.625709 N -81.886264 `1, AWL&
6.Is(are)the well(s)o% Permanent or [)Temporary. Signature of Certified Well Contract Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or [)% 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 constr•tuction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair tender#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 345 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifefiffer•ent(example-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 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:
(ix.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) 12 Method of test: AIR 24c.For Water Supply&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: 2CUPS completion of well construction!to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Divkino„r WAeer n