GW1-2021-07420_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
Well Contractor Name ® FROM TO DESCRIPTION
It. fL
2136-A ® ft. tL
NC Well Contractor Certification Number ^ _15.OUTER CASING for multi-eased wells OR LINER'if a Gcable
CAMP'S WELL AND PUMP -mom TO DIAMETER THICKNESS MATERIAL
Company Name — mJ 0 ft 63 ft- 6.125 ! 1°' SDR21 PVC
SW21-0382 16.INNER CASING OR TUBING `eothermat closed-loop)
2.Well Construction Permit#: `An COgGt�'O� FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County NY, ,etc) ft. It. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
In7 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1"Geothen-nal
on-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring ;Recovery
jection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19:=SAND/GRAVEL PACK if a 'lieahle
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
A quifer Test �Stormwater Drainage
Experimental Technology Subsidence Control ft. fft.Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets.if necessa(I Ieating/Coohng Return) 00ther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type, rain size etc.
0 ft. 63 ft- CLAY
4.Date Well(s)Completed: Well ID# 64 ft. 405 ft* GRANITE
ft.Sa.Well Location: ft.
TIMOTHY MCCLELLAN ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2250 BIGGERSTAFF LOOP NEBO, NC 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.Certification:
35.641673 N -81.864467 W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor j 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 01C.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 a,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-I 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 if different(example-3@200'and 2@I00� 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 Iniection 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: 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) 7 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016