GW1-2022-07926_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT - 1,19wnrERzoNEsn_ y s, s fin'
FROM TO DESCRIPTION
Well Contractor Name (t, [t. I
4545-A tt, rt.
NC Well Contractor Certification Number 15aOUTERi ASING(for m�Ii IH cascd)well's`0R LINER"if a"'llestile b e t ..
CAMP'S WELL&PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 75 ft- 6.125 In' SDR21 PVC
Company Name L)(�(�
.7.7 �16�INNER@ASINGiOR�1iUBINC�fi'eathermal�ol'ost:d=too
2.Well Construction Permit#:.SW17—Qr FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction penuits fl.e.VIC,County,State,Variance,etc.) ft. ft. in.
in.
3.Well Use(check well use):
:k17 S MEEPTt i st ft. ft.
Water Supply Well: FROM TO I DIAMETER SLOTSIZE I THICKNESS I MATERIAL
Agricultml [3MunicipaVPublic R. ft. I in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In.
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
—- Non-Water Supply Well: p ft. 20 ft BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge QGroundwater Remediation LK
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 3;20bDRILhINGlLOG,attach addttidhal aheuStb^Ifnecessa
Geothermal (Heating/Cooling Return) rjOther(explain under#21 Remarks FROM I TO DESCRIPTION color,hardness solUrock type,grain size etc.
o 0 ft. 75 ft. CLAY
4.Date Well(s)Completed: b`�— �� Well ID# 76 ft 345 ft GRAN ITE
5a.Well Location:
ROGER METCALF tt. tt. + e� a :;7 V y.-_
Facility/Owner Name Facility ID#(if applicable) ft fL O
771 CENTENNIAL RD.
I(pvtr£ 1 (3f�
Physical Address,City,and Zip ft ft 3 i
RUTHERFORD 721ti=REm1i>:Rxs� -�_> ..U,. .... ., :. ..."..:,_��,.,. 'ice _. .>_�•� L
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:
35.46810 N -81.90294 W,
V 0<1- 5- Zz
6.Is are the well s rx Permanent or Tem ora Signature of Certified Well Contractor a Date
( ) O _ P ry _. _ i - — — — — --
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: Yes or %JNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Consrnuction Standards and that a
Ifthis is a repair,fill out known well construction information and explain die 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: 345 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:20 (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) 50 Method of test: AIR 24c.For Water Supply&Ini Iction Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE z CUPS completion of well construction to the county health department of the county
13b.Disinfection type: Amount: n P
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016