GW1-2022-03660_Well Construction - GW1_20220321

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
DAV I D CAMP 14 WAT,ER 7ANES ,;= „z ,
FROM TO DESCRIPTION
Well Contractor Name
rt. ra P
2136-A
rt. rt. �
NC Well Contractor Certification Number 15i OUTERfCASING for'roulli=ea`ed wells AR LINER'ds"'IIcab7e
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
ft- 75 n- 1 6.125 In- SOR21 PVC
Company Name
SW21-0199 16'=1NNER,CASINGtORUB'TING, euttiermel<clo'sed?loo
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.
17`SCREEN&.: .,
Water Supply Well: FROM TO MDIAMETER SLOT SIZE THICKNESS MATERIAL.
_ Agricultural E)Municipal/Public I ft. ft. lin•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• g, in.
Industrial/Commercial DResidential Water Supply(shared)
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19•$AND/GRAVEL PA(7C f a "`licable n .€ s
_Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control It. ft.
_.Geothermal(Closed Loop) Tracer 20r.I)RIILLING'LOG'attacti atlditonal sheetiit aecesss`.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock rain size etc
0 ft. 75 ft• GRANITE
4.Date Well(s)Completed: J'� Well ID# 76 ft 565 ft. CLAY
ft. ft.
5a.Well Location:
KEN SEPTOR
Facility/Owner Name Facility lD#(if applicable) ft. ft. R^ T w
COAL PIT MTN. DR. 15-� k)�L)16rby rti /l ft. ft. I ' ` ' -
Physical Address,City,and Zip ft. ft. MAR 21 ZO _
MCDOWELL 2I;RENIARIcs
_ r
.7777777777777,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.567156 N -81.908908 W �"'
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contrac(6r Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or MNo with 1 SA 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back o(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-3Q200'and 2@1001 construction to the following:
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10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 276994636
13a.Yield(gpm) 30 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
13b.Disinfection type: CHLORINE Amount: 2- 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