GW1-2022-09146_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
GARRETT J. PADGETT - %I4NWXURMONE
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A rt. ft.
NC Well Contractor Certification Number M 00 UTEWWAS INGffdWdIfi!,8Wil�vellii tORMIN 11Fstilc
CAMP'S WELL&PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft. 1 75 ft. 6.125 in. SOR21 PVC
Company Name
1;is16%INNER+'G9INGUIt1MUBhVG'""eoftie`rmaltct5sed=lo`5"'
2.well Construction Permit#: 13919 FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
ft. fL in.
3.Well Use(check well use):
Water supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural ElMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) SS:GROU7t<' `tom :xyF' *rn. y s u'l ' t '`<`•'=€ =
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 IL 13ENTENITE POURED 14 BAGS
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation . . -
9t9:'f3AND/GR:A�VEIiIP:AGK1 f`a lfoable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \' QStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) OTracer 3O�DRIEVINCs}LQG 1t 111 i?addlii�nalistieab"tf necessa ':
FROM I TO DESCRIPTION color,hardness solUrock type,grain size etc.
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks 0 g 75 ft. CLAY
4.Date Well(s)Completed: r�b Well 1D# 76 rt' t25 rt' GRANITE
5a.Well Location: -
MICHAEL&NICOLE FREDELL
Facility/Owner Name Facility ID#(if applicable) ft. ft. — 3 " 02 2
1326 LONG CREEK RD., KINGS MTN. rt. ft.
Physical Address,City,and Zip
GASTON ta211tE7vInRx:B
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:
35.29364 N -81.34202 �, �I_wd
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified Well Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or XJNo wirh.15A NCAC 01C.0100 or,15A NCAC 02C.0100 Well Construction Standards and that a
1f(his is a repair,fill out known well construction information and explain lite 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 200'and 2@1001 construction to the following:
10.Static water level below top of casing:'40 (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) 100 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 constructi in to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016