GW1-2022-08167_Well Construction - GW1_20220428

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
GARRETT J. PADGETT 44,WATER.`ZONESW-'k y...�.
Well Contractor Name FROM TO DESCRIPTIONft, ft.
4545-A
NC Well Contractor Certification Number „15:OUTEW.CASING:_fortmultfic'Mkil;elI l:ORiblN.W job
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 65 I'L 6.125 In. SDR21 PVC
Company Name
FARM �16INNER(CAS1NGi e Ult"�T.UBING dtheitinsilclosed=loo n .,� :":z 3 x,.:-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS Y MATERIAL
List all applicable well constriction permits(i.e.UIC,County,Stale,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. tt. in.
-
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
x Agricultural ©Municipal/Public % tt. in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) fa to ►n•
IndustriaUCommercial ©Residential Water Supply(shared) 18iCdR0UT';:'-,,.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
tt. ft.
Aquifer Recharge QGroundwater Remediation
+19:SSAND/GRAYEIJEACK?ilia"'Heable
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage
Experimental Technology ❑Subsidence Control
Geothermal(Closed Loop) Tracer t-20 DIULTITNC�.LOGi atiectirsdditlonal stieetiifcneceies` ".' f, z '>
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness sollfrock�.type, rain size etc.
0 ft. 65 ft. CLAY
4.Date Well(s)Completed: Well ID# 66 fI• 465 ft• GRANITE
5a.Well Location: n• n.
GARY CAMP
Facility/Owner Name FacilitylD#(if applicable)
US-64
Physical Address,City,and Zip tt. ft. AP
RUTHERFORD 2tE°REMARKS c s?::/?�a < 4 r, /•.z X:xLws.` _ n> e f
County Parccl Identification No.(PIN) vy?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(if well field,one lat/long is sufficient) 22.Certification:
35.448856 N -81.895199 W
6.Is(are)the well(s)ox Permanent or Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consrntcrion Standards and that a
If 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 I GW-I 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: 465 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii event(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 30 (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,iUnderground 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016