GW1-2021-02643_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: s
1.Well Contractor Information:
DAVID CAMP 14,WATERZONES. r:= ,
FROM TO DESCRIPTION '
Well Contractor Name
fit, fit.
2136-A
NC Well Contractor Certification Number 151=0UTER CASINGS for maid;'esed w@Ils OR4LINER a liceble ->%
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 100 ft. 6.125; in. SOR21 PVC
Company Name
168756 .FROM
OR;TUBl1V(ss` eotliermal closed'?Ioo _
2.Well Construction Permit#: 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):
Water Supply Well: FROM TO „DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: URI
20 ft. BENTENITE POURED14BAGS
Monitoring _�Recovery ft.
Injection Well: fit.
Aquifer Recharge Groundwater Remediation
YELPAGK`fa"`7icable
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) Tracer 40 DRMU NGLOG attach4iddid6fidl sheets if necei sa
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soiUrock/ rains etc.)
/ 0 ft. 100 ft- CLAY
4.Date Well(s)Completed: / 4/-,2 Well ID# lot it. 245 ft- GRANITE
5a.Well Location: tt. ft.
OAKWOOD HOMES/PAULA GUERIN ft. fit.
Facility/Owner Name Facility ID#(if applicable) ft.
124-1 BASSETT DR., CASAR tt. ft. r 20
Physical Address,City,and Zip fit. fit. uF,1��
CLEVELAND 21= MaRxs .
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.Certi atfon:
35.557744 N -81.589772 W
6.Is(are)the well(s)opermanent or [3Temporary Signature of Certified Well Conhactoi 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 E)No with 15A NCAC 01C.0100 or 15A NCAC 01C.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 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 245 (it-) 249. For All Wells: Submit (this form within 30 days of completion of well
For multiple wells list all depths(different(example-3©200'and 2Q100') construction to the following:
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10.Static water level below top of casing: 20 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: C
(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) 100 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
13b.Disinfection type: Amount: P , 'county P county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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