GW1-2021-07407_Well Construction - GW1_20210921 (2)

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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
2136-A 1��1 ft. TO
1 � \t IL
ft.
NC Well Contractor Certification Number SE q,S�n� 15.OUTER CASING for multi cased wells OR LINER if a licable
CAMP'S WELL AND PUMP CO. ,��Q'(DC�IaC OtN FROM To DIAMETER TtF Ess MATERIAL.
0 ft 115 ft 6,125' SDR21 PVC
Company Name �C�p( o�
13445 16.INNER CASING OR TUBING(eothertnal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER SLOT SIZE TIICKNESS MATERIAL
Agricultl 13Municipal/Public ft. ft.ura in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft.
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 I Recovery ft. f.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation ;
19.SAND/GRAVEL PACK if a "livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft-
'Geothermal
(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) "
FROM IP TO DESCRIPTION(color,hardness,soii/rock type,gmin size,etc.
2 / 0 & 115 ft• CLAY
a
4.Date Well(s)Completed: -/ _��/`7 Well ID# 116 rt' 205 rt' GRANITE
5a.Well Location:
JANET BOWEN
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1035 BESS TOWN RD. BESSEMER CITY 28016 ft. ft
Physical Address,City,and Zip ft. ft.
GASTON 21.REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.321494 N -81.273775 W
6.Is(are)the well(s)@)Permanent 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: 13Yes 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: 205 (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@100� construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
10 13a.Yield(gpm) 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 Ito 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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