GW1-2021-07956_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES :.
Well Contractor Name FROM TO DESCRIPTION
fL ft.
2136-A
ft. tL
NC Well Contractor Certification Number 15.OUTER'CASING for multi-cased wells OR LINER tf a' Gcable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 75 ft 6.125 in' SDR21 PVC
EH 21151 16.uvNER cnsnvc OR TUBING eotnermal cloaca-too _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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 I THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
_Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) FL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft' BENTENITE POURED 14 BAGS
Monitoring [3Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Oi Tracer 20.DRILLING LOG(attach additional sheets if necessary),
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 75 fL CLAY
`'� .
4.Date Well(s)Completed: ! ,*,Q Well ID# 76 ft. 205 ft• GRANITE
5a.Well Location: ft. ft.
ROBERT SHINESTUHL ft. ft. e1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
843 SCOGGINS RD. ft' ft. OA
(�
Physical Address,City,and Zip ft. ft.
POLK 21.REMARKS ttQi�r J
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:
35.192211 N -81.986087 W
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well ContractolF 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: EJYes or E)No with 15A NCAC 01C.0100 or 15A NCAC o2C.010o Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@I001 construction to the following:
10.Static water level below top of casing:40 (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,sUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: AIR 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subrtiit 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