GW1-2021-06927_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
It. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-sed wells OR LINER`d a licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER T®ctaVEss MATERIAL
0 ft. 75 ft. 6.125: In' SDR21 PVC
Company Name
E H 19-0 V CG V 36 16.'INNER CASING OR TUBING eothermal closed-lou
2.Well ConstructionPermit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rt.e.UIG County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: FROME TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. it,
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 Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 1ieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control IL ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 75 it• CLAY
4.Date Well 4-19-2021 it s)Completed: Well lD# 76 405 ft. GRANITE
Sa.Well Location: ft ft. c l a; „
KARR DURWOOD ft• ft.
r
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. o A
2021
GATEWAY LN., MAIDEN ft. ft'I a v�11,3t};n i rof;cning U'ilit
Physical Address,City,and Zip ft. ft. Lei FIZ sec ton
on
LINCOLN 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.Cergt cation'
35.526520 N -81.166565 W ��4
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6.Is(are)the well(s)oPermanent or Temporary Signature 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 E]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction 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:
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: 405 (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'and 2r&100) construction to the following:
10.Static water level below top of casing: 55 (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 Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: lr construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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