GW1-2022-09304_Well Construction - GW1_20221006

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT J. PADGETT a AIRWAtfEIVZONESL��:5r b u
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4545-A
ft. ft.
NC Well Contractor Certification Number 15:UUTERtCASING.for inult[=caedtwells ORtLINER ife" Usable 1 3 i �s CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
p ft. gp ft. 6.125 In. SDR21 PVC
Company Name �116ilINNEItCCASING ORtTUBING 'eotberiiiolselosed4id
2.Well Construction Permit#: 170961 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well consMiction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
t lt1 SCREENt--!;dam_
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) ;18+GROUTa!-
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 20 ft* BENTENITE POURED 14 BAGS
Monitoring 13 Recovery
Injection Well:
ft ft.
Aquifer Recharge [)Groundwater Remediation
;414 SAND/GRA4YEI.ffFACK`if;s"'ll stile e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage R. ft.
Experimental Technology ; Subsidence Control
Geothermal Closed Loop) Tracer 20:DRIL'LINGtLOG,ettacb_adith " "( p) Q .e
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness solitrock Me,grain size etc.
Q 0 ft. gp ft. CLAY
4.Date Well(s)Completed: '0 2-Well ID# 91 ft. 125 fL GRANITE
ft. ft.
5a.Well Location:
CALEB REINWAND
Facility/Owner Name Facility ID#(if applicable)
501 ALEX D OWENS DR.
Physical Address,City,and Zip R. R. OCT 0 V
2022
CLEVELAND 21 REMARKS;
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:
35.18056 N -81.35754 `,lr
6.Is(are)the well(s)E)Permanent or Temporary Signs ure of Certified Well Contractor Date
By signing this form,1 hereby,certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or oNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!'this is a repair,fill out known well construction information and erplain 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:
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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 125 ft 24a.24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(exam))le-3(a1200'and 2©100) construction to the following:
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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) 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 construction ito 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