GW1-2021-05993_Well Construction - GW1_20211008

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A ft rL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
CAMP'S WELL AND PUMP CO. FROM TO DIAI�TER THICKNESS MATERIAL
0 f1• 90 IL 6.125 1 ' I SRD21 PVC
Company Name
S W20-0414 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft. It. rn•
Geothermal(Heating/Cooling Supply) DResidential 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 it' BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ❑(Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ❑(Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiVrock e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks)
0 ft• 90 it- CLAY
4.Date Well(s)Completed: �. d -2- Wefl D# 91 ft. 605 ft. GRANITE
ft. ft
5a.Well Location:
MICHAEL SHEAVES ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
84 LINNCOVE TRAIL ft. It. T Q 2
Physical Address,City,and Zip ft. ft. nit
MCDOWELL 21.REMARKS in f3rrn
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 �--G
35.553620 N -81.878631 W
6.Is(are)the well(s)oPermanent or ❑(Temporary 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: Yes or XJNo 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: 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'and 2@100D construction to the following:
10.Static water level below top of casing:60 (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
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
I
13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Iniection Well s: 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-I North Carolina Department of Environmental Quality-Division of Water Resources t Revised 2-22-2016
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