GW1-2022-08173_Well Construction - GW1_20220428

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
GARRETT J. PADGETT
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A
NC Well Contractor Certification Number 5,iQUTERVMSINGi fm mulfikiW dills OR LiNEIt if` 11kilik X
CAMPS WELL AND PUMP CO. FROM TO DIAMETER THICKNESS I MATERIAL
0 tt• 130 tt• 6.125 in' SOR21 PVC
Company Name ,.16 s�
INNER,CASINGtORhTUBING""euthrinsl�el eosed-!"o'o"'" �s,�, ,:,.;��•�.�'�. r:,y.:
2.Well Construction Permit#'W22-00 10 FROM 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.
u;17:3t?RI�'EN?G`i?' "'{b4.:.>c`,'�k<...art'. '.fx+�sl.�✓.Jh.":`. a7r '� .'c`l°a
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. lo•
IndustriaUCommercial .QResidential Water Supply(shared) GIFOUT .s•r..111�. ; . a_,%,t `. ask,r T` r ,•? gFr` x � `
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Weill:
Aquifer Recharge Groundwater Remediation *� ,m
?l9SAND/GRAVEL"'PACT{•if,a IlCebie :,t:,r, a
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. fL
Experimental Technology [3Subsidenee Control
Geothermal(Closed Loop) Tracer M2011 1RIMlb €i O"G:attachsadditibnel•ahcetslfinee€ass":'`� � f+ *u ?1 :u
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soft/rock a ram size etc.
0 tt. 130 tt• CLAY
4.Date Well(s)Completed: ! I ! Well ID# 131 tt• 185 tt• GRANITE
5a.Well Location: ft. tt.
AMY GAITHER ft' rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
428 DILLS RD.
Physical Address,City,and Zip ft. ft. 8
RUTHERFORD 721:REMARxs
urn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(ifwell field,one lat/long is sufficient) 22.Certification:
35.263940 N -81.913447 W
A44.p� 1
-a�
6.Is(are)the well(s)o Permanent or Temporary Signature of Certified Well Contract Date
By signing this form,I herebv certify that the wents)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or EJNo with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Constnucrion Standards and that a
Ifthis is a repair,full out known well construction information and explain tl:e 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 als6attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 185 (tt•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli Brent(ecample-3 t@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 50 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:
(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 Sootily&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: 2CUPS 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