GW1-2022-08700_Well Construction - GW1_20220907

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-1)
1.Well Contractor Information:
GARRETT J. PADGETT
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A
NC Well Contractor Certification Number
1'SgOiIT,F,R�°A51biiC,for inrilii�ca�ed6�elli IU1ti�IIVEItE'�ii"`licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 110 ft* 6.125, in- SDR21 PVC
Company Name 1-6-,'' 11"SY1,CLARzsTf?B1iV eothern "cl3sed:bE`
SW21-0474 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well construction permits(i.e.UIC,Counr3,State, Variance,etc.)
ft. tt. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©MunicipaVPublic [t. tt. In,
Geothermal(Heating/Cooling Supply) Xf Residential Water Supply(single) ft. It. in.
IndustriaUCommercial Residential Water Supply(shared) 18:(GROti?i
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 Remediation194 e1ND/GR�!` I.�lPArCK� ;� "111ttiI
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test >.. 13Stormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 4ti0 RIIji0T1CL1LfUC;a'ttiieh ridditi`ooa '�tstifinecesmess,,
FROM TO DESCRH'I'fON color hardness aolUrock type,ain size etc.
Geothermal eatin ooling Return) rJOther(explain under#21 Remarks) 0 ft. 110 ft. CLAY
4.Date Well(s)Completed: Well ID# 111 ft. 245 ft. GRANITE
5a.Well Location: �±
JAY DILLER
Facility/Owner Name Facility ID#(if applicable)
it. ft. I LULL
r
1601 PINEY KNOB RD. it. rt. ;. .. !{�Ur.:
Physical Address,City,and Zip
RUTHERFORD ,21 'MARKS.
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:
N -82.05866 J-i ZZ
35.46129 w 4X .�
6.Is(are)the well(s)MPermanent or OTemporary
Signature of Certified Well Contract orU Date
By signing this form,1 hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: QYes or x®No with 15A NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constriction 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mdtiple wells list all depths ifdii different(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: 80 (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) 25 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.
V.—rw.t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016