GW1-2021-02121_Well Construction - GW1_20210709

-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVI D CAMP 14.WATER ZONES'
FROM TO DESCRIPTION
Well Contractor Name
ft. ft
2136-A �UL p g 2021 ft ft.NC Well Contractor Certification Number �$S g UD 15.OUTER CASING for multi-cased wells bR LINER tf a livable
CAMP'S WELL AND PUMP CO. trlfolm,3tlon pf action FROM TO DIAMETER THICKNESS MATERIAL
-- IR S� 0 ft. 30 ft. 6.125' ln' SDR21 PVC
Company Name
13443 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. in.
I REE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. fL
Industrial/Commercial E3Residential Water Supply(shared) -
18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 it• BENTENITE POURED 14 BAGS
Monitoring ®Recovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVELPACK it a livable .- a'-
_,Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 10.DRELLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRYMON color,hardness,soilfrock type,gmin size,etc.)
9 0 ft. 30 it CLAY
4.Date Well _ =-s)Completed: -2-1 Well ID# 31 it 505 it' GRANITE
5a.Well Location:
HEATHER DELLINGER ft ft. RECENtu
Facility/Owner Name Facility ID#(if applicable) ft. ft.
817 WHITE-JENKINS RD. BESSEMER CITY ft ft.
Physical Address,City,and Zip ft. ftinformpltion Processing Unit
GASTON 21.REMARKS r)4,,R Sianilon`
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:
35.312339 N -81.233422 W '
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Conte 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: DYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 I 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: 505 (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,
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
ROTARY above, also submit one copy ofthis 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) 10 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
CHLORINE 2 CUPS completion of well construction to the coup health department of the county
13b.Disinfection type: Amount: P h' P
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016