GW1-2022-08168_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contractor Information:
i
GARRETT J. PADGETT W 4."iWArExtzoNEs
FROM TO DESCRIPTION
Well Contractor Name f
ft. ft.
4545-A ft. fL I
NC Well Contractor Certification Number - . - -
F15 O17.7tERl'CASINGf fo mu1N=c's'sedwells"ORtLtINER fta v11ca61e i�����
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 80 ft. 6.125 in. SDR21 PVC
Company Name
SW21-0466 i'6 INNER/GASING;OR§.7'UBINOr'eothecmiil closedplou'WW: . �'
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. tt. in.
Water Supply Well: tAM.'SOREENr1';`y3 �:.r�:.
PP y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural QMunicipaUPublic tt. tt. in
Geothermal(Heating/Cooling Supply) [BResidential Water Supply(single) ft. tt. in.
IndustriaUCommercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
"9.JSA1!TD'/,GMVEIt}EA(nIC_`iG;a'"""lic`a'tile 7,r
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer e
FROM TO DESCRIPTION color,hardness,soil/rock c rain size etc.
Geothermal(Heating/Coolingg/Return) Other(explain under#21 Remarks) 0 ft. 60 ft. CLAY
4.Date Well(s)Completed:Y 19—.Zz Well.ID# 61 ft 560 ft GRANITE
5a.Well Location:
CHRIS&JENNIFER SPRATT/NORTHPOINT
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1180 HARRIS=HOLLY SPRINGS RD. ft. fr. ;z
Physical Address,City,and Zip ft. ft.
RUTHERFORD
County Parcel Identification No.(PIN) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: w
(if well field,one lat/long is sufficient) 22.Certification:
35.250359 N -81.901028 �,
Z4,L&- �— —'A�
6.Is(are)the well(s)E% Permanent or OTemporary Signature of Certified Well Contractor U Date
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: 13Yes or QNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis 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 tinder#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-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: 560 (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 1Q100� construction to the following:
10.Static water level below top of casing: 60 (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 Infection 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
s
13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE 2 CUPS completion of well construction to the coup health department of the
13b.Disinfection type: Amount: P , �' P county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016