GW1-2022-04866_Well Construction - GW1_20220520

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
G'f ,. # 4 y,✓e f{'Z}`'ys!.f`yr,,. ..,�f} ` q't{t�i�h� r_:y���.. ,.y.2
GARRETT J. PADGETT
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4545-A
NC Well Contractor Certification Number ;]S TOUTEE� ASING ror fiiuMtl isidiwetls',OR°LINERi Pa"'Ilcable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 87 ft. 6.125 in' SDR21 PVC
Company Name vl/�I _ O n %16-ANNER CASING UR?TI)B1NG d&Vesmel'closed4do
2.Well Construction Permit#' J 11 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Ct. ft. in.
3.Well Use(check well use): ft. ft. in.
"17:;SCREENt�G'�r+S+ tf,a r.4.r 3t "41,... '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) MiResidential Water Supply(single) ft. ft.
htdustrial/Commercial OResidential Water Supply(shared)
I[ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTE141TE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
r+lA:iSAND/GRi1VEI3tiPACIC:IfB"'Itcatllei.;;„% n�s, it.`tt.,..a,.i', �,`.:'.�:>p r yY
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStorinwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer A2071DRILIti G;EUGi aftiicfi4ddttloniirslieet'4ruie6dii
Geothermal(HeatingtCooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness soll/rock type,grain size etc.)
1- �J 0 ft. 97 ft. CLAY
4.Date Well(s)Completed: `T—O- '� Well ID# 96 rt' 165 rt' GRANITE
Sa. ell L cation: rt. ft.
f
Ma— Q � e- ft. ft.
(� T 1 J•a^-..
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
CINNAMON RIDGE ft. ft. MAY 9, 9
Physical Address,City,and Zip ft. ft.
RUTHERFORD tit^IREM:IRKS a r it ri. t; L u
� .5,.:, , F<,::.5 .i»f,"s e,- •1I Jr7 s ..
County Parcel Identification No.(PIN) �'x tiri'C+Zro 1t iVr'ti�VLL r�vi+,{,�I.l I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(if well field,one IaVlong is sufficient) 22.Certification:
35.422108 N -82.000342 `,ir c4z"dlz , i '
6.Is(are)the well(s)IM Permanent or OTemporary Signature of Certified Well Contractor 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: [3Yes or M®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and arplain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
8.For Geaprobe/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: 185 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'mid 2@1001 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,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:
(Le.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) 30 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: 2 CUPS completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016