GW1-2021-02603_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 1-4.WATER ZONES
Well Contractor Name FROM ft. TO DESCRIPTION
fL
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LUVER"if a livable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER 711MEss MATERIAL
0 ft. 95 ft. 6.125 in. SDR21 PVC
Company Name
EH2O-04586 �16.INNER CASING OR TUBING eotherinal closed-lou
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL fL in.
3.Well Use(check well use): ft. ft. in.
i7.SCREEN
Water Supply Well:
FROM TODIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Oi Residential 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 it. 20 ft. BENTENITE POURED 14 BAGS
_;Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL PACK rf a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 95 ft. CLAY
4.Date Well(s)Completed: V r�I V�I Well ID# 96 ft. 505 ft, GRANITE
ft. ft.
5a.Well Location:
RON GUNTER
Facility/Owner Name Facility lD#(ifapplicable) ft fttj
3043 FISH POND RD.,CHERRYVILLE,NC 28021 ft.
Physical Address,City,and Zip
LINCOLN 21.REMARKS' U{
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:
35.429123 N -81.394993 W j
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor; Date
By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with 15A NCAC 02C.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 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: 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 1@1001 construction to the following:
10.Static water level below top of casing: 20 (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) 10 Method of test: AIR 24c.For Water Supply&Infection 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
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