GW1-2021-06955_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP .� ? 9) 14.WATER ZONES
Well Contractor Name �- � ' /3,,,-A v -•� FROM TO DESCRIPTION
ft. ft.
2136-A P,�,4Y X J 2021 iL fL I
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER ifa ticable
CAMP'S WELL AND PUMP CO. �'�f'`�`�� `{�
,'z7vrl i- FROM TO DIAMETER THICKNESS MATERLtI.
I7:5v�1 r� l.or�i{1il
0 fL 85 ft' 6.125 in' SDR21 PVC
Company Name
S W21-0121 MINIVER CASING OR TUBING: eothermid.closedaoo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft. TO
in.
3.Well Use(check well use): fL ft. in.
17;SCREEN
Water Supply Well:Itp y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural OMunicipal/Public it. ft. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in,
Industrial/Commercial ®]Residential Water Supply(shared) -18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge OI Groundwater Remediation
19.SAND/GRAVEL PACK it a 'licable '
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control iL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION(color,hardness,soil/mck rain six etc.
Geothermal(Heating/Cooling Return) C3Other(ex lain under#21 Remarks)
p ft. 85 ft. CLAY;
4.Date Well(s)Completed: '(/ Well ID# 86 ft• 605 ft, GRANITE
ft. ft.
5a.Well Location:
JIM &SHARON CLEMENT
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
36 BELLA VISTA WAY, NEBO ft. ft.
Physical Address,City,and Zip ft. ft.
MCDOWELL 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.Ce ation:
35.567482 N -81.906316 W _�7 z/
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor: Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 19No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy 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 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: 605 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'annd'2@1001 construction to the following:
10.Static water level below top of casing: J (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
1/
13a.Yield(gpm) ! Method of test: AIR 24c.For Water Suooly&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016