GW1-2022-08699_Well Construction - GW1_20220428

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
GARRETT J. PADGETTr.
Well Contractor Name FROM TO DESCRIPTION
4545-A n
NC Well Contractor Certification Number 15at)UTERiCASING'for mu18=csawi weUi OR?L`INER if a `Ucetile i
CAMP'S WELL & PUMP CO. FROM TO I DIAMETER THICKNESS MATERIAL
0 ft• 60 ft. 6.125 in. SDR21 JPVC
Company Name I16iiINNE1tsGA5INGiUR`rT_UBINGv`eotticrmnlclosed=loo
2.Well Construction Permit#: SW21—0400 FROM I TO DIAMETER THICKNESS MATERAAI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. rt. In.
3.Well Use(check well use): R. tt. in.
�6-17:1SCRFENG' x t3. h,xtK t aQe e..: 11;1•wt8v�� h Y 'vrt:" sf�x
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n. tt. In.
[]Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft. ft. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
01ni ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD6 AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery
Injection Well:
ft. tt.
❑Aquifer Recharge OGrotmdwater Remediation ..19e ..y
.SAND/13PAVEL PACK'ii;a Iteatil'e . ,. c r4 i1. "`> „. ::.•.`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL IEMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. rt.
❑Experimental Technology ❑Subsidence Control ft. ft.
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❑Geothermal(Closed Loop) ❑Tracer g20:+DRIL+LINGiLUG attach'adidHoaalsle€tsiifnecessi e ? {k '?e.. 4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 rt. 60 rt. CLAY
4.Date Well(s)Completed: Well ID# 61 rt. 465 tt. GRANITE
5a.Well Location: tt• tt.
R&B ENTERPRISES OF SALISBURY
Facility/Owner Name Facility ID#(if applicable) APR
ft. ft.
2456 OLD FORT SUGERHILL RD. rt. ft. `
rt. rt. r.• :,,,
Physical Address,City,and Zip �1�a..,•_:;�,��
MCDOWELL zi*REI4IARKS_t : rtis •; f >t� °` ,:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.601919 N -82.140508 w
6.Is(are)the well(s):-19Permanent or ❑Temporary Signature ofCcrtified Well Contractor Dat
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box):You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:465 (ff) Submit this GW4 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 r(�i 200'and 2@a/00')
10.Static water level below to of casing 80 (ft 24a. For All Wells: Original';form to Division of Water Resources (DWR),
P g ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use•'+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: ROTARY
Program,1636 MSC,Raleigh,NC 27699-1636
24c.For Water Su !,I and O �n-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county envtronmental health department ot the county where ms—RaTrH
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 10 Method of test:All R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
CHLORINE Amount: 2 CUPS
13b.Disinfection type:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018