GW1--06377_Well Construction - GW1_20241025

,y wPrant=Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
GARRETT PADGETT zIa WAt!'ER>zoNEs ....,__ _ .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4545-A • It. ft.
NC Well Contractor Certification Number '153'OUTER CASING(fors_niulHwa`std%wells)*QR>IiINERS(If'ap Ilelble) -
CAMPS WELL AND PUMP CO FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 83 ft• 6.125 In' SDR21 PVC
Company Name *IC INNERCASING;OR;TUBING(i eotheriniikeloscd=laop)Va ':: .. .
2.Well Construction Permit#: SW23/24-0074 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. ; tn.
3..Well Use(check well use): ft ft in
ki7 SCREEN K.:-1 .A -,r .s.' Ti-i r ,r,;... , F' .!e ?_ .
Water Supply Well: FROM TO DIAMETERS SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaVPublic ft. ft. in.1
, Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft, ft. In.I
Industrial/Commercial DResidential Water Supply(shared) 1S GROUT l'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. BENTENITE POURED
Monitoring - •Recovery . " ft. - ft.
' Injection Well: ft. ft. •
Aquifer Recharge D Groundwater Remediation „
`•19S SANDIGRAVEL.PACK'.(if'applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
Aquifer Test • N. E3 Stormwater Drainage ft. ft. ,
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer %i20i7DRILLING;LOGi(nttaeh•additional sheeisaf>neeessary)r; -. .
FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
3Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
0 ft• 63 •ft• DIRT
4.Date Well(s)Completed:8-12-24 Well ID# ft. ft.
5a.Well Location: w ft. 605 ft. BLUE GRANITE
BRUCE TAYLOR ft. It.
Facility/Owner Name Facility ID#(if applicable)
274 MOSSY OAK TRAIL ft. ft. 1 0 r T 2 7024
Physical Address,City,and Zip ft ft
MCDOWELL 163600999252 •21:11EMARICS,= . ;It,t ;, :"' .,`:'• ,
11...(k: i..A.
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one latllong is sufficient) 22.Certification:
35.5541180 N•-81.8915250 �, i s .7, q--?0,2y
6.Is(are)the well(s) Permanent or`Temporary Sien�ttire of Certified Well Contrpct6r, Date
�^P
By signing this form,I hereby c
le
rtify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction I jorination 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:
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 I 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: 805 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100't construction to the following: 1.
10.Static water level below top of casing: 120 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I.
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
AIR 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servic j Center,Raleigh,NC 27699-1636
(gpm) Method of test:
0 FRACKED 2-3 PUMPED
13a.Yield m 24c.For Water Supply&Infection 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 CUP CHLORINE • completion of well constructioti 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