GW1-2021-02123_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 7.l
DAVI D CAMP r� �, �`� 14.WATER ZONES
r� y FROM TO DESCRIPTION
Well Contractor Name 2�L1
L ft. ft.
2136-A
lti fL tL '
NC Well Contractor Certification Number prQGe�sln�u 15.OUTER CASING forlti cased wells OR LLNER'iSSfs licable
CAMP'S WELL AND PUMP CO. InIGO -3tiO g SeC11,00 FROM TO muDIAMETER THICKNE MATERIAL
V 0 It- 60 ft- 6.125 1 in- SDR21 PVC
Company Name
16.INNER CASING OR TUBING 'eothermnl closed-loop), ..._
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 1F7ROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_'Agricultural ®Municipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK"of a 'licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soivrock type,grain six etc.)]
0 ft. 80 ft. CLAY
..--
4.Date Well(s)Completed: 'Z 3-1Z Well ID# 61 ft' 565 ft' GRANITE
ft. ft.
5a.Well Location:
BRIAN HENSON ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
92 HENSON HIGHWAY LN. ft. ft.
Physical Address,City,and Zip ft. ft.
POLK 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:
35.198481 N -82.257623 W '
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractoif 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: E)Yes or M-i No 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: 565 (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 1@1001 construction to the following:
10.Static water level below top of casing: 30 (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,Underground 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&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE zcuPs 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 Resourlces Revised 2-22-2016
I