GW1-2021-07661_Well Construction - GW1_20211215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: _T
1.Well Contractor Information:
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DAVID CAMP 14.WATER ZONES P
Well Contractor Name FROM TO I DESCRIPTION
ft. tt.
2136-A r<. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a Ilcable
CAMP'S WELL& PUMP CO., INC. FROM TO DIAMETER TRICKNEss MATERIAL
1 R• 155 fL 6.125 In• SDR21 PVC
Company Name
SW21-0336 16.INNER CASING OR TUBING eothermal 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. ft. in.
3.Well Use(check well use): ft. ft.
17.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft, ft. fin•
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' BENTENITE 14 BAGS POURED
Monitoring DRecovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK !f applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,amin size,etc.
0 tt• 155 fL
11/03/21 4.D Completed: Well ID#
156 ft- 245 ft, CONSOLIDATED ROCK
(s)
ft. ft.
5a.Well Location:
MATTHEW HAMILTON ft. ft
Facility/Owner Name Facility ID#(if applicable)
BILL COLLINS RD ft. ft. UEC 1 5 ?021
Physical Address,City,and Zip ft. ft.
POLK 21.REMARKS tn1iRN a '►8r i
1/
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O `
(ifwell field,one lat/long is sufficient) 22.Certification:
35.272542 N 82.144526 W l 12/09/21
6.Is(nre)the well(s)OX Permanent or []Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certify the well(
was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo with 15A NCAC 01C.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: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 155 (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 Injection 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
13a.Yield(gpm) 50 Method of test: AIR 24c.For Water Supply&Injection 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