GW1-2021-03904_Well Construction - GW1_20210823

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ++�
1.Well Contractor Information: i
DAV I D CAMP �ER(•ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15-'0UTER-.GASING f ii.'multt-ciiied wells i0R LE4911 tf a"livable o DIAMETER
CAMPS WELL AND PUMP CO.
0 ft. 130 ft. 6.125 SDR21 PVC
Company Name -
EH-21077 16"INNERGA8WWOWTMING eother`Sialclosed=l`oo
2.Well Construction Permit#: FROM TO DIAMETER I 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
Water Supply Well: •17 SCREEN+';>;, - ,•� r.n_- A x ..'.r,>*�
PP Y FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18.GROUT
❑Ilri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK tfii "livable '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING`-LUG'ittech ad liiionot,sheets if,neck'ssa"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solifrock type,grain size etc.
0 ft 130 ft CLAY
4.Date Well(s)Completed: 'a Well lD# 131 ft 325 ft GRANITE
ft ft.
5a.Well Location:
ALAN WARREN ft rt. y
Facility/Owner Name Facility ID#(if applicable) ft. ft.
GREEN RIVER HIGHLANDS ft. rt. �3 0
rt (Y U,
Physical Address,City,and Zip rt. J - �•.•-)
POLK Zl'REMARIES`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well `field,
�7one lattlong is sufficient) 22.Certification:
3r, D�J 0ly N r I/ J�O W
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infonnation and explain the nature of the 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 construction info
(add'See Over'in Remarks Box):You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL-INSTRUCTIONS
9.Total well depth below land surface: 325 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100) I
24a. For All Wells: Original!form to Division of Water Resources (DWR),
10.Static water level below top of casing: 65 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use"+"
f Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:AI R
13b.Disinfection type: CHLORINE Amount: 2 CUPS j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018