GW1-2021-02235_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 1alwATERzoNEs
FROM TO DESCRIPTION
Well Contractor Name ,
2136-A
NC Well Contractor Certification Number S OUTERiCASING:toy multi4,ased walla)_<OR!tINER-Je"licable 'F;
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER TIIICKNESS MATERIAL
0 ft.
t 115 ft. 6.125 in. SDR21 PVC
Company Name 16"V4NER;CASING'tSIt.TUBWC` eotherival closed'-too x
2.Well Construction Permit#: 28323 FROM TO DIAMETER I THICKNESS I 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.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:!)Agricultural Agricultural E)MunicipaL/Public
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. tt. in.
lndustriaVCommercial DResidential Water Supply(shared) -
'.18. -
I'l
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft. BENTENITE POURED 14 BAGS
-]Monitoring :Recovery ft. ft.
Injection Well:
tt. ft.
_Aquifer Recharge Groundwater Remediation
.19 SAND/GkAN EtUVAt>7C' f-a"'ticsble
:)Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 1ITracer i20.4DRILLING.'L•OGr attach additional sheetB.if,necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness sail/rocktype, rain A etc.
0 ft. 115 ft- CLAY
4.Date Well(s)Completed: Well ID# 116 ft. 245 ft. GRANITE
Sa.Well Location: ft. ft.
SARAH CROSLAND a, ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. e! F"
602 DAVIS RD. BELMONT, NC 28012
Physical Address,City,and Zip ft. ft. B `ZQ2
GASTON 21:-REMARxs
County Parcel Identification No.(PIN) ^1t-30031�rOLOSSt[iC� .
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: `
35.218889 N -81.016038 W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi,6�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or R)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 it different(example-3Q200'and 2@1001 construction to the following:
g
10.Static water level below top of casing:40 Division of Water Res l u'rces,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241b.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 IC nter,Raleigh,NC 276994636
13a.Yield(gpm) 12 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: z CUPS completion of well construction Ito!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