GW1-2022-01549_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.;WATEWvZbNEs .
FROM TOI DESCRIPTION '
Well Contractor Name ft. ft
2136-A ft.
NC Well Contractor Certification Number I53:OUTER-CASING. 6ir'muiti=eaged webs Ox 151II!i if a'"livable t
CAMP'S WELL AND PUMP CO. FROM TO I DIAMETER TlHCKNESS MATERIAL^
0 ft. 80 ft- 6.125 1" SDR21 PVC
Company Name .16 INNER,CASINGsOR:[USING eothermsl eltisei131iio ."
2.Well Construction Permit#: EH-21832 FROM TO DIAMETER I TEICKNESS I MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): ft ft in
flWISCREEN,=
Water Supply Well: . T
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_.;Agricultural OMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. Y0 ft. BENTENITE POURED 14 BAGS
_ monitoring _Recovery tt. fL
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation -
.19:SANDIGRAVEL'RACK i5i'_livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20°DRILtiING=LOG;attiich addltional stieetsstf neeessi' ,,r
FROM TO DESCRIPTION color,hardness,soll/rock rains etc
Geothermal eating/Cootin Return) Other(explain under#21 Remarks tt. ft.
0 60 CLAY
4.Date Well(s)Completed: Well ID# 61 ft 265 it GRANITE
5a.Well Location:
RICKY BARKER
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft. �i 2� t
233 MEDFORD RD.
Physical Address,City,and Zip (
POLK �2 REiHARxs' '
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:
35.267503 N -82.083453 W (I
6.Is(are)the well(s)OPermanent or.OTemporary Signature of Certified well Contactor Mte
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: [3Yes or E)No with 15A NCAC 02C.0100 or 1 SA 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 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: 265 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/different(example-3 rQe 200'and 2®100') construction to the following:
10.Static water level below top of casing:40 (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 Iniection Wells: Inladdition 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&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 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