GW1-2022-04854_Well Construction - GW1_20220520

WELL C NSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT is aWATERZOI!TEs:y3I?WYz�x:=;o iv .�t ,k r;Y. E Sn :> ,� 3ia' c.m;
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A
ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASIN_G;for.multL eesed:wells OR LINER,Ifi>; 'llcatile
a vv�c:t
CAMPS WELL AND PUMP CO. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft- 115 ft- 6.125 in, SDR21 PVC
Company Name r
16:,IN1vER=EASING OR�TUBINGs'eotliermaFdosed>loo`,,
S W 17-0303
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in,
3.Well Use(check well use): ft. ft. in.
rit1'%SCREENz,it`:PF tL v ..3zi_'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) fL ft.
Industrial/Commercial 13Residential Water Supply(shared) ri8:'GROUT .,re'. �. a- .::.. x x.'.E '" �`•fi:.-�4 :',� o ., kk:*
Itrl ation .FROM 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 QGroundwater Remediation
=1 9:SANDIGRAVEVYACW ifs bill le _�.- ei�' }^F r' ?n-.,..b 4 r:*
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E]Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer #;r20�DRlVVlNG LOG'attachiaddltio iaLaheefs;Ifinecesse". is '30 -?=.t
Geothermal (Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soll/mck e,grain size etc.)
0 tt. 115 ft- CLAY
4.Date Well(s)Completed: 1 — 1 Well ID# 116 ft- 505 ft* GRANITE ,� n+ 1
ft. tt. s a r ^ Y y e" 9 "
Sa.Well Location:
JOHN&JENNIFER CANNING rt. u. 202?
Facility/Owner Name Facility ID#(if applicable) ft. ft.
81 AUSABLE TR. rt. rt. rlt,;;: ;1rv'ra
Physical Address,City,and Zip ft. ft. l - ;tyYpy l i(In i tCli V t v"
MCDOWELL
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: „
35.561498 N -81.905706 W
6.Is(are)the well(s)OX Permanent or 13Ternporary Signature of Certified Well Contractor Q Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [ONo - with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Nell Construction Standards and that a
#'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,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: 505 (tt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
lfwarer 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) 2 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-I North Carolina Department of Environmental Quality-Division of Water Re-11 oo
II •